FIDA Participant Coverage Determination, Appeals and Grievances

How to Request a Coverage Determination for Medical Care

How to request coverage for medical care?

Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want at the contact information listed below. You, your doctor, or your representative can do this.

Call:
1-855-462-3167 8 a.m. – 8 p.m., 7 days a week
TTY: 711

Fax:
718-765-2027

Write:
Elderplan, Inc.
6323 7th Avenue
Brooklyn, NY 11220

How quickly are coverage determinations made?

When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard coverage decision means we will give you an answer within 14 calendar days after we receive your request. A fast coverage decision means we will answer within 72 hours. To get a fast coverage decision, you must meet two requirements: (1) You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care you have already received.) (2) You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

What happens if we decide completely in your favor?

If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our coverage decision, we will authorize or provide the coverage by the end of that extended period.

What happens if we deny your request?

If our answer is no to part or all of what you requested, we will send you a detailed written explanation as to why we said no.

How to request an appeal?

If we say no to your request for coverage for medical care, you decide if you want to make an appeal. To start an appeal you, your doctor, or your representative, must contact us. If you are asking for a standard appeal, make your standard appeal in writing by submitting a request or calling us at the contact information listed below. If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. If you are asking for a fast appeal, make your appeal in writing or call us. You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.

Call:
1-855-462-3167 8 a.m. – 8 p.m., 7 days a week
TTY: 711

Fax:
718-765-2027

Write:
Elderplan, Inc.
6405 7th Avenue, 3rd Floor
Brooklyn, NY 11220

If your health requires it, ask for a “fast appeal” (you can make a request by calling us). If you are appealing a decision we made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal.” The requirements and procedures for getting a “fast appeal” are the same as those for getting a “fast coverage decision.” To ask for a fast appeal, follow the instructions for asking for a fast coverage decision. If your doctor tells us that your health requires a “fast appeal,” we will give you a fast appeal. When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.

What happens if we decide completely in your favor for your appeal?

If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal.

What happens if we deny your request for your appeal?

If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal.

How to Request a Coverage Determination for Part D

What is a coverage determination?

Whenever you ask for a Part D Prescription drug or non-Part D drug (Medicaid covered drug) benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug or non-Part D drug (Medicaid covered drug). Coverage determinations requests include non-formulary exception requests, prior authorization, step therapy, and quantity limit exception requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of preferred drugs (formulary). If you request an exception, your physician must provide a statement to support your request.

You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

If you have problems getting the prescription drugs you believe we should provide, you can request a coverage determination. We use the word “provide” in a general way to include such things as authorizing prescription drugs, paying for prescription drugs, or continuing to provide a Part D Prescription drug or non-Part D drug (Medicaid covered drug) that you have been getting.

If your doctor or pharmacist tells you that Elderplan FIDA Total Care will not cover a prescription drug, you should contact us (contact information is listed at the bottom of the page) and ask for a coverage determination. The following are examples of when you may want to ask us for a coverage determination:

  • If you are not getting a prescription drug that you believe may be covered by Elderplan FIDA Total Care.
  • If you have received a Part D Prescription drug or non-Part D drug (Medicaid covered drug) you believe may be covered by Elderplan while you were a participant, but we have refused to pay for the drug.
  • If we will not provide or pay for a Part D Prescription drug or non-Part D drug (Medicaid covered drug) that your doctor has prescribed for you because it is not on our list of preferred drugs (also called a formulary). You can request an exception to our formulary.
  • If you are being told that coverage for a Part D Prescription drug or non-Part D drug (Medicaid covered drug) that you have been getting will be reduced or stopped.
  • If there is a limit on the quantity (or dose) of the drug and you disagree with the requirement or dosage limitation.
  • If there is a requirement that you try another drug before we will pay for the drug you are requesting.
  • You bought a drug at a pharmacy that is not in our network and you want to request reimbursement for the expense.

How to request a coverage determination

The purpose of this section is to give you more information about how to request a coverage determination or appeal a decision by us not to cover or pay for all or part of a drug, vaccine or other Part D (including non-Part D drugs) benefit.

When we make a coverage determination, we are giving our interpretation of how the Part D Prescription drug or non-Part D drug (Medicaid covered drug) benefit that is covered for participants of Elderplan FIDA Total Care apply to your specific situation. Elderplan FIDA Total Care makes a coverage determination about your Part D Prescription drug or non-Part D drug (Medicaid covered drug) or about paying for a Part D Prescription drug or non-Part D drug (Medicaid covered drug) you have already received. The coverage determination made by Elderplan FIDA Total Care is the starting point for dealing with requests you may have about covering or paying for a Part D Prescription drug or non-Part D drug (Medicaid covered drug). If your doctor or pharmacist tells you that a certain prescription drug is not covered, you should contact Elderplan FIDA Total Care and ask us for a coverage determination. With this decision, we explain whether we will provide the prescription drug you are requesting or pay for a prescription drug you have already received. If we deny your request (this is sometimes called an “adverse coverage determination”), you can appeal the decision by going on to Appeal Level 1. If we fail to make a timely coverage determination on your request, it will be automatically forwarded to the independent review entity, Appeal Level 2, for review.

The following are examples of coverage determinations:

  • You ask us to pay for a prescription drug you have already received. This is a request for a coverage determination about payment. You can call us at 1-866-443-0935, 24 hours a day, 7 days a week (for TTY, call 711), to get help in making this request.
  • You ask for a Part D drug or non-Part D drug (Medicaid covered drug) that is not on Elderplan’s FIDA Total Care list of preferred drugs (also called a formulary). This is a request for a “formulary exception.” You can call us at 1-866-443-0935, 24 hours a day, 7 days a week (for TTY, call 711), to ask for this type of decision.
  • You ask for an exception to our plan’s utilization management tools—such as dosage limits, quantity limits or step therapy requirements. Requesting an exception to a utilization management tool is a type of formulary exception. You can call us at 1-866-443-0935, 24 hours a day, 7 days a week (for TTY, call 711), to ask for this type of decision.
  • You ask that we reimburse you for a purchase you made from an out-of-network pharmacy. In certain circumstances, out-of-network purchases, including drugs provided to you in a physician’s office, will be covered by the plan. You can call us at 1-866-443-0935, 24 hours a day, 7 days a week (for TTY, call 711), to make a request for payment or coverage for drugs provided by an out-of-network pharmacy or in a physician’s office.

Who may ask for a coverage determination?

You can ask us for a coverage determination yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you. Some other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement, Appointment of Representative, must be sent to us at:

CVS/caremark
P.O. Box 52000, MC 109, Phoenix, AZ 85072-2000

Or you may fax it to: 1-855-633-7673

You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify

Standard vs. fast coverage determination

Do you have a request for a Part D Prescription drug or non-Part D drug (Medicaid covered drug) that needs to be decided more quickly than the standard timeframe? A decision about whether we will cover a Part D Prescription drug or non-Part D drug (Medicaid covered drug) can be a “standard” coverage determination that is made within the standard timeframe (typically within 72 hours), or it can be a “fast” coverage determination that is made more quickly (typically within 24 hours). A fast decision is sometimes called an “expedited coverage determination.”

You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. Fast decisions apply only to requests for Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Part D drug that you already received.

Standard Coverage Determination

To ask for a standard decision, you, your doctor or your appointed representative should call us at 1-866-443-0935, 24 hours a day, 7 days a week (for TTY, call 711). Or, you can mail a written request, or completed Request for Coverage Determination Form to:

CVS/caremark
P.O. Box 52000, MC 109, Phoenix, AZ 85072-2000

Or you may fax it to: 1-855-633-7673

Fast (Expedited) Coverage Determination

You, your doctor or your appointed representative can ask us to give a fast decision (rather than a standard decision) by calling us at 1-866-443-0935, 24 hours a day, 7 days a week (for TTY, call 711). Or, you can mail a written request or completed Request for Coverage Determination Form to:

CVS/caremark P.O. Box 52000, MC 109, Phoenix, AZ 85072-2000

Or you may fax it to: 1-855-633-7673

Be sure to ask for a “fast,” “expedited,” or “24-hour” review.

  • If your doctor asks for a fast decision for you or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.
  • If you ask for a fast coverage determination without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast coverage determination, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a grievance if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast coverage determination, we will give you our decision within the 72-hour standard timeframe.

Certain drugs require supporting documentation from your physician (non-formulary drugs, prior authorizations, step therapies, and quantity limits). Your physician may use the available forms (or ANY other written forms) to assist in this process.

Medication Exception Request Form For Non-Formulary Drug, Quantity Limit and Step Therapy
Prior Authorization Request Form
Participant Reimbursement Form

Physicians assisting with coverage determinations may also use the Request for Coverage Determination Form.

How quickly are coverage determination decisions made?

Standard Coverage Determination: For a standard coverage determination about a Part D drug, which includes a request about payment for a Part D drug that you already received, generally, we must give you our decision no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. However, if your request involves a request for an exception (including a formulary exception or an exception from utilization management rules—such as dosage or quantity limits or step therapy requirements), we must give you our decision no later than 72 hours after we have received your physician’s supporting statement, which explains why the drug you are asking for is medically necessary. If you are requesting an exception, you should submit your prescribing physician’s supporting statement with the request, if possible.

We will give you a decision in writing about the prescription drug you have requested. If we do not approve your request, we must explain why and tell you of your right to appeal our decision. Appeal Level 1 explains how to file this appeal. If you have not received an answer from us within 72 hours after we have received your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

Fast Coverage Determination: For a fast coverage determination about a Part D drug that you have not received, we will give you our decision within 24 hours after you or your doctor ask for a fast review—sooner if your health requires. If your request involves a request for an exception, we will give you our decision no later than 24 hours after we have received your physician’s supporting statement, which explains why the non-formulary or non-preferred drug you are asking for is medically necessary.

We will give you a decision in writing about the prescription drug you have requested. If we do not approve your request, we must explain why and tell you of your right to appeal our decision. Appeal Level 1 explains how to file this appeal. If we decide you are eligible for a fast review, and you have not received an answer from us within 24 hours after receiving your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

If we do not grant your or your physician’s request for a fast review, we will give you our decision within the standard 72-hour timeframe discussed above. If we tell you about our decision not to provide a fast review by phone, we will send you a letter explaining our decision within three calendar days after we call you. The letter will also tell you how to file a grievance if you disagree with our decision to deny your request for a fast review and will explain that we will automatically give you a fast decision if you get a doctor’s support for a fast review.

What happens if we decide completely in your favor?

If we make a coverage determination that is completely in your favor, what happens next depends on the situation.

Standard Coverage Determination: For a standard decision about a Part D drug, which includes a request about payment for a Part D drug that you already received, we must authorize or provide the benefit you have requested as quickly as your health requires, but no later than 72 hours after we received the request. If your request involves a request for an exception, we must authorize or provide the benefit no later than 72 hours after we have received your physician’s supporting statement. If you are requesting reimbursement for a drug that you already paid for and received, we must send payment to you no later than 30 calendar days after we receive the request.

Fast Coverage Determination: For a fast decision about a Part D drug that you have not received, we must authorize or provide you with the benefit you have requested no later than 24 hours after receiving your request. If your request involves a request for an exception, we must authorize or provide the benefit no later than 24 hours after we have received your physician’s supporting statement.

What happens if we deny your request?

If we deny your request, we will send you a written decision explaining the reason why your request was denied. We may decide completely or only partly against you. For example, if we deny your request for payment for a Part D drug that you have already received, we may say that we will pay nothing or only part of the amount you requested. If a coverage determination does not give you all that you requested, you have the right to appeal the decision.

How to File an Appeal for Part D

What is an appeal?

An appeal is a formal way of asking us to review our coverage decision and change it if you think there was a mistake. If you or your provider disagrees with the decision, you can appeal. In all cases you must start with a Level 1 Appeal.

How to request an appeal

To start your appeal, you, your representative or your provider must contact us. You can call us at 1-855-462-3167, 8 a.m. to 8 p.m., 7 days a week (TTY users should call 711), or you can send your appeal in writing. If you decide to appeal in writing, you should mail all documents to: Elderplan FIDA Total Care, Appeals and Grievances Department, 6405 7th Avenue, 3rd Floor Brooklyn, NY 11220. TTY users should call 711.

If you would like your provider or someone else to represent you in filing the appeal, you will need to either complete an “Appointment of Representative” form or write and sign a letter indicating who you want to be your representative. The form or letter gives the other person permission to act for you. You can get an “Appointment of Representative” form by calling Participant Services or downloading it here: English | Español. We must receive the completed Appointment of Representative form or signed letter before we can review your appeal.

You must ask for your appeal within 60 calendar days from the date on the letter that you received informing you of the coverage decision. If you should miss the deadline and you have a good reason for missing it, you should let us know, and we may give you more time to make your appeal. If your appeal is about Medicaid prescription drugs, we will give you an answer within 7 calendar days from the date of your appeal. For all other appeals, you should receive a response within 30 calendar days from the date we received the appeal.

Quality of care complaints

If your grievance is about a Quality of Care concern, you can file the grievance directly with Elderplan; if you prefer, you can file the grievance directly to the Quality Improvement Organization or you can file with both Elderplan and the Quality Improvement Organization at the same time.

You must file your grievance within 60 calendar days after you had the problem you would like to complain about. You can expect a response from us within 30 calendar days or sooner if your situation requires it. If you are unhappy with our response to your grievance, you may file an external grievance.

In addition to filing a complaint with Elderplan, you can also tell Medicare and New York State Department of Health. Medicare can be reached at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048 or visit the Medicare webiste English | Español. To file a complaint with the New York State Department of Health, you can call the helpline at 1-866-712-7197.

If your grievance is about disability access or language assistance, you can file a grievance with the Office of Civil Rights. The New York Regional Office of Civil Rights can be reached at: Office of Civil Rights, U.S. Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza – Suite 3312, New York, NY 10278. Tel: 1-800-368-1019. TTY users can call 1-800-537-7697.

Appeal Level 1

A Level 1 Appeal is the first appeal to Elderplan FIDA Total Care. We will review the coverage decision to see if it is correct. The person reviewing your appeal will be someone at Elderplan FIDA Total Care who is not part of your Interdisciplinary Team (IDT) and was not involved in the original decision. Upon completing the review, we will send you our decision in writing. Should you need a fast decision because of your health, we will also try to notify you by telephone. If the Level 1 Appeal is not decided in your favor, we will automatically forward the appeal to the Integrated Hearing Office (IAH) for a Level 2 Appeal.

If your IDT, Elderplan FIDA Total Care, or authorized specialist decided to change or stop coverage for a service, item or drug that you have been receiving, we will send you a notice before taking the proposed action. If you disagree with the action, you can file a Level 1 Appeal. We will continue covering the service, item or drug if you request your Level 1 Appeal within 10 calendar days of the postmark date on our notice or by the intended effective date of the action, whichever is later. If you met this deadline, you can keep getting the service, item or drug with no changes while your appeal is pending. All other services, items or drugs (that are not the subject of your appeal) will also continue with no changes.

Appeal Level 2

If the Level 1 Appeal is not decided in your favor, we will automatically forward the appeal to the Integrated Hearing Office (IAH) for a Level 2 Appeal.

Grievance Process for Medical and Part D

What is a grievance?

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with Elderplan, our network providers, or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you may file a grievance if you are unhappy with the quality of the care you have received, are unhappy with how our member services has treated you, or if you have a problem with waiting times when you fill a prescription.

How to file a grievance

You can call Participant Services at 1-855-462-3167, 8 a.m. to 8 p.m., 7 days a week. (TTY users should call or send us a letter telling us about your grievance.) You can mail your letter to: Elderplan FIDA Total Care, Appeals and Grievances Department, 6405 7th Avenue, 3rd Floor Brooklyn, NY 11220. or fax it to 718-765-2027.

Elderplan’s Participant Services will assist you with filing your complaint and advise you if any additional information is needed. If you are sending a letter to us, you should at a minimum let us know your name, identification number, a telephone number where you can be reached, and give us a description of the issue or problem you are having. If you need help getting started with a complaint, you can also contact the FIDA Participant Ombudsman for assistance. The Participant Ombudsman can be reached at 1-844-614-8800 (TTY users can call 1-844-614-8800) or online at icannys.org.

Quality of care complaints

If your grievance is about a Quality of Care concern, you can file the grievance directly with Elderplan; if you prefer, you can file the grievance directly to the Quality Improvement Organization or you can file with both Elderplan and the Quality Improvement Organization at the same time.

You must file your grievance within 60 calendar days after you had the problem you would like to complain about. You can expect a response from us within 30 calendar days or sooner if your situation requires it. If you are unhappy with our response to your grievance, you may file an external grievance.

In addition to filing a complaint with Elderplan, you can also tell Medicare and New York State Department of Health. Medicare can be reached at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048 or visit the Medicare website: English | Español. To file a complaint with the New York State Department of Health, you can call the helpline at 1-866-712-7197.

Disability access or language assistance complaints

If your grievance is about disability access or language assistance, you can file a grievance with the Office of Civil Rights. The New York Regional Office of Civil Rights can be reached at: Office of Civil Rights, U.S. Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza – Suite 3312, New York, NY 10278. Tel: 1-800-368-1019. TTY users can call 1-800-537-7697.

If you would like to request an aggregate number of grievances, appeals and exceptions filed with FIDA Total Care please contact our Participant Services Department at 1-855-462-3167, TTY: 711 from 8am to 8pm, 7 days a week.

Looking for information?

Questions? Call Elderplan today.

1-855-462-3167

[TTY 711]

for the hearing impaired

Hours of Operation:
8 a.m. - 8 p.m., 7 days a week

Elderplan FIDA Total Care
is available in the Bronx, Kings, New York, Queens, Richmond and Nassau Counties.