Understanding the complaint process
Elixir Insurance provides meaningful procedures for timely hearing and resolution of grievances or complaints. We also have a protocol for escalation of grievances when warranted or requested.
A grievance is different from an appeal because usually it will not involve coverage or payment for prescription drugs included in Medicare prescription drug coverage benefits. Examples of a grievance include dissatisfaction with your medical care, poor customer service, lack of respect for your privacy, poor or hard-to-understand written communications and a lack of timeliness in our handling of coverage decisions and appeals. A grievance must be made within 60 days of when the situation occurred. Below are examples of issues that might lead to a grievance being filed.
- Quality of medical care - If you are unhappy with the quality of care you received.
- Concerns about privacy - Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?
- Disrespect, poor customer service or other negative behaviors - Has someone been rude or disrespectful to you or have you been mistreated by customer service?
- Waiting times - If you have been kept waiting too long by pharmacists or by Elixir Insurance staff.
- Cleanliness - If you are unhappy with the cleanliness or condition of a pharmacy.
- Misinformation or miscommunication - Do you believe we have not given you a notice that we are required to give, or do you think written information we have given you is hard to understand?
Complaints about the time it takes to receive answers to coverage determination or appeals - If you have already submitted a request for a coverage decision or an appeal and you think it’s taking too long, you can file a complaint. Examples of such complaints include:
- You asked for a "fast coverage decision" or a "fast appeal," and we have said we will not provide that.
- If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made.
- If deadlines for reimbursements are not being met.
- When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a complaint.
Please note that submitting requests or questions related to coverage determinations and appeals follow a different process and are not part of the complaints process.
How do I file a grievance?
For more information regarding grievances, coverage determination requests, or appeals, refer to Chapter 7 of your Evidence of Coverage or visit the Medicare website. If we cannot help with your issue and you wish to file a formal complaint, you may contact Medicare. Please note: by clicking on a link, you will be leaving the Elixir Insurance website.
How Can I Request Information Related to Grievances, Appeals and Exceptions?
You may request aggregate numbers of grievances, appeals, and exceptions filed with Elixir Insurance, or specific information regarding the status of grievances or appeals you have filed, by calling Member Services at 1-866-250-2005 (TTY users may call 711). Member Services is open 24 hours a day, 7 days a week.
Or visit the CMS Medicare website at www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp. Please note by clicking on this link, you will be leaving the Elixir Insurance website.