Appeals and Grievances

Grievances:

You can file a complaint (also known as a grievance) with Elderplan’s Participant Services if you have concerns or are unhappy with the quality of care you received, wait times, accessibility to care, poor customer service or any other benefit or health related issue that you are unhappy with. 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.

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. 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.

Appeals:

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.

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.

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 you can get the form on the Medicare website at http://www.cms.hhs.gov/. 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.

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.