Appeals and Grievances

If you’re unhappy with Elite Health Plan, our providers or vendors, your coverage, or want to make a special request, we want to help. A grievance or appeal or exception allows you to tell us what’s on your mind so we can help you. You have the right to file these requests. Here’s some information to help you get started with your grievance, appeal or exception.

Grievances, appeals, and exceptions explained

Grievance: A type of complaint you make about our plan, providers, or pharmacies, including a complaint concerning the quality of your care. This doesn’t involve coverage or payment disputes.
Appeal: with our decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs you already got. You may also make an appeal if you disagree with our decision to stop services that you’re getting.
Exceptions: A type of coverage decision that, if approved, allows you to get a drug that isn’t on our formulary (a formulary exception), or get a non-preferred drug at a lower cost-sharing level (a tiering exception). You may also ask for an exception if our plan requires you to try another drug before getting the drug you’re asking for, if our plan requires a prior authorization for a drug and you want us to waive the criteria restriction, or if our plan limits the quantity or dosage of the drug you’re asking for (a formulary exception).

Who can submit grievances, appeals, and exceptions

Medicare Part C (Medicare Advantage):
- You
- Your physician
- Or a representative you appoint. To act on your behalf, they must complete and return an Appointment of Representative Form.
Medicare Part D (Prescription drug coverage):
- You
- Your doctor or another prescriber
- Or a representative you appoint. To act on your behalf, they must complete and return an Appointment of Representative Form.

You can appoint anyone as your rep with the following If you want a friend, relative, or other person to be your representative, call Member Services at 800-958-1129 (TTY: 711) and ask for the Appointment of Representative form. You can also download the Appointment of Representative form here, in English or Spanish.

A representative who is appointed by the court or who is acting in accordance with state law also can file a request on your behalf after sending us the appropriate legal representative document (primarily a power of attorney for health care). You don't need to complete an Appointment of Authorized Representative.

Important Timeframes for Medicare Managed Care (Part C) Appeals:

Part C: (Medical)

65 days* from the date of our Notice of Denial of Medical Coverage or Payment

We will have to notify you of our appeal decision within:

72 hours for fast appeal
7-day for Part B drugs appeal
30 calendar days for standard appeal
60 calendar days for a payment appeal

For more details on additional appeals right, please refer to Chapter 9 in your Evidence of Coverage.

*Extension: If you miss the deadline to file, you can request an extension. You must provide a valid reason for the delay (e.g., illness, natural disaster). The plan may or may not accept it.

Medicare Managed Care (Part C) Appeals Chart with Timeframes

Important Timeframes for Medicare Prescription Drug (Part D) Appeals:

Part D:

65 days* from the date of our Notice of Denial of Medicare Prescription Drug Coverage

We will have to notify you of our appeal decision within:

72 hours for a fast decision if your doctor confirms that waiting for a standard appeal decision could seriously harm your health.
7 calendar days for standard appeal.
14 calendar days for standard payment appeal.

For exception requests, the timeframe begins when your doctor or other prescriber provides a supporting statement, if not provided during the initial review.

For more details on additional appeals right, please refer to Chapter 9 in your Evidence of Coverage.

*Extension: If you miss the deadline to file, you can request an extension. You must provide a valid reason for the delay (e.g., illness, natural disaster). The plan may or may not accept it

Medicare Prescription Drug (Part D) Appeals Process with Timeframes

Submit your appeal or grievance:

Mail or Fax:

You can download a pdf version of the Appeals and Grievances Form here.

To submit by mail, send it to:

Elite Health Plan,

P.O. Box 1489

Orange, CA 92856

Or fax it to:

840-237-2980

For a Part D Drug reconsideration or exception, please go to the drug coverage page.

Phone:

For grievances (standard or expedited) please call 1-800-958-1129. (TTY: 711).

For expedited grievances, please complete the form and fax to: 840-237-2980.

Medicare Part D late enrollment penalty reconsideration (appeal)

The Centers for Medicare & Medicaid Services (CMS) may require you to pay a late-enrollment penalty (LEP) when enrolling in Medicare Part D if:

You didn’t join a Medicare Part D plan when you were first eligible
You didn’t have other “creditable prescription drug coverage,” such as coverage through your employer, for 63 continuous days

Qualifying for an LEP review

If you meet 1 or more of the below conditions, you can appeal CMS’s LEP decision by requesting a reconsideration.

You believe that you had creditable prescription drug coverage. Coverage is creditable if it is at least as good as Medicare’s standard prescription drug coverage that you received through sources such as an employer, the VA or other sources.
You had prescription drug coverage but didn't get a notice that explained if the drug coverage was creditable.
You received or still receive Extra Help from Medicare to pay for prescription drug coverage.
You received or still receive assistance from a State Pharmaceutical Assistance Program and the coverage is considered creditable.
You couldn’t enroll in a Medicare Part D plan due to a serious medical emergency.
You couldn’t enroll in a Medicare Part D plan during the period stated by your current Medicare drug plan.

How to appeal an LEP decision

You or your representative can request an appeal. You must appeal within 60 days of the date on the letter you received informing you of an LEP.

If you’ve asked someone to act for you, that person must send proof of his or her right to represent you with the appeal form. Proof can be:

A power of attorney form
A court order
An Appointment of Representative Form

Appeals made after 60 days may only be considered if CMS decides there was a valid reason for the delay.

Fill out the LEP reconsideration and mail it to the address shown or fax it to the number listed. Make sure to keep a copy for your personal records. Send proof of why you believe you meet the requirements for the appeal.

Note: Please don’t send original documents. Always send copies.

If you need more information, visit the C2C website: Part D Appeals (opens in new window).

C2C is an independent contractor that works with CMS to review and resolve disputes between CMS and Medicare plan members.