Grievance Process
We encourage you to let Elderplan Member Services know right away if you have questions, concerns or problems related to your prescription drug coverage. We can be reached at 1-800-353-3765, 8 a.m.–8 p.m., 7 days a week (for TTY, call 1-800-662-1220).
This section gives the rules for making complaints in different types of situations. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from Elderplan or penalized in any way if you make a complaint.
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 or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem with waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, the cleanliness or condition of a network pharmacy, or other such situations.
A grievance is different from a request for a coverage determination because it usually will not involve coverage or payment for Part D prescription drug benefits (concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process).
What types of problems might lead to you filing a grievance?
- You feel that you are being encouraged to leave (disenroll from) Elderplan.
- Problems with the member services you receive.
- Problems with how long you have to spend waiting on the phone or in the pharmacy.
- Disrespectful or rude behavior by pharmacists or other staff.
- Cleanliness or condition of pharmacy.
- If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination.
- You believe our notices and other written materials are difficult to understand.
- Failure to give you a decision within the required timeframe.
- Failure to forward your case to the independent review entity if we do not give you a decision within the required timeframe.
- Failure by the plan to provide required notices.
- Failure to provide required notices that comply with the Centers for Medicare & Medicaid Services (CMS) standards.
In certain cases, you have the right to ask for a “fast grievance,” meaning your grievance will be addressed within 24 hours.
If you have a grievance, we encourage you to first call Member Services at 1-800-353-3765, 8 a.m.–8 p.m., 7 days a week (for TTY, call 1-800-662-1220). We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this Elderplan’s Member Grievance Program. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.
You may call 1-800-353-3765, 8 a.m.–8 p.m., 7 days a week (for TTY, call 1-800-662-1220) to file your grievance or you can mail it to us at:
Elderplan, Inc.
Appeals and Grievances Department
6323 Seventh Avenue
Brooklyn, NY 11220
By fax, at (718) 491-7226
For quality of care complaints, you may also complain to Island Peer Review Organization. Complaints concerning the quality of care received under Medicare may be acted upon by the plan sponsor under the grievance process, by an independent organization called Island Peer Review Organization, or by both. For example, if an enrollee believes his or her pharmacist provided the incorrect dose of a prescription, the enrollee may file a complaint with Island Peer Review Organization in addition to or in lieu of a complaint filed under the plan sponsor’s grievance process. For any complaint filed with Island Peer Review Organization, the plan sponsor must cooperate with Island Peer Review Organization in resolving the complaint.
Quality of care complaints filed with Island Peer Review Organization must be made in writing. An enrollee who files a quality of care grievance with Island Peer Review Organization is not required to file the grievance within a specific time period.
You can contact Island Peer Review Organization at:
Island Peer Review Organization
1979 Marcus Avenue
Lake Success, NY 11042-1002
1-800-331-7767
