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Appeals & Grievances

Appeals & Grievances

To view the formal Appeals and Grievance Processes, please review Chapter 9 of the Evidence of Coverage as applicable:

Grievances

A grievance is any complaint other than one that involves a coverage determination. A grievance can be about administrative issues, such as AgeWell New York staff or doctors’ attitudes and/or their interactions with you. Grievances may include complaints about the timeliness, appropriateness, access to and/or setting of a provided health service, procedure or item.

For example, dissatisfaction with wait times when filling a prescription or the cleanliness or condition of a network facility or provider office. You as a member or your representative must file a grievance no later than 60 days after the event or incident that caused the grievance. If a request to have a coverage decision, coverage determination, reconsideration or coverage re-determination expedited is denied, you can file an expedited grievance.

You or someone that you appoint to act on your behalf can represent you and can file a grievance.  (Appoint a Representative Form [1]) Someone you appoint can be a relative, friend, advocate, attorney, physician or other prescriber. If you wish to appoint a representative, you can use the form or you can send a written statement with the following information included:

To appoint a representative or to start the Grievance process, we are available Monday to Friday 8 a.m. to 8 p.m.

You can write to us at

AgeWell New York
Attn: Appeals & Grievances Department 
1991 Marcus Avenue, Suite M201 | Lake Success, New York 11042

Or fax to 1-855-895-0778.

Grievances can be submitted either orally or in writing. You are able to communicate with us by calling at 1-866-237-3210. You can also submit a complaint at Medicare.gov [2] or call 1-800-Medicare.

Appeal

An appeal is a complaint you make when you want us to change a decision we made about your care. An appeal is a request from you, member designee or non-contracted provider to reverse or modify an initial determination to deny, reduce or discontinue services or the denial of payment for medical care. The time frame for filing an appeal is 60 calendar days from the date of the notice of the adverse determination. You can file one when we:

You will get a letter from us when any of these actions occur. This is called a “Notice of Action.” You can file an appeal if you think that the action was made in error.

You or your doctor can ask for an expedited appeal. We will give you an expedited appeal if your doctor says waiting could seriously harm your health. You may ask for an expedited appeal without a doctor’s help. We will decide if you need an expedited decision.

You or your provider must call or fax us to ask for an expedited appeal.

Call 1-866-237-3210 (TTY 1-800-662-1220) | Fax to 1-855-895-0778

If your request was filed verbally, written notice is not needed. For expedited appeals, we will call you. We will send a letter with the appeal decision within three days.

If you ask for an expedited appeal and we decide that one is not needed, we will:

AgeWell New York must make its reconsidered determination as quickly as the member’s health condition requires, but no later than 30 calendar days from the date we receive the request for a standard appeal. The time frame will be extended by up to 14 calendar days by AgeWell New York if the member requests the extension, or also may be extended by up to 14 calendar days if AgeWell New York justifies a need for additional information and documents how the delay is in the best interest of the member.

When AgeWell New York extends the time frame, we will notify the member in writing of the reasons for the delay, and inform the member of the right to file an expedited grievance if the member disagrees with AgeWell New York’s decision to grant itself an extension. For appeals related for a request for reimbursement (services that have already been received and you have paid for), AgeWell New York must make its reconsidered determination no later than 60 calendar days from the date we receive the request.

In some cases you may be able to continue receiving the services while you wait for your appeal to be decided. You may be able to continue the services that are scheduled to end or be reduced if you ask for this:

If your appeal results in another denial, you may have to pay for the cost of any continued benefits that you received. If we deny your appeal and you are not satisfied, you can appeal further using the fair hearing process or external appeals.

To obtain an aggregate number of grievances, appeals and exceptions filed with the plan, please call us at 1-866-237-3210, Monday through Friday, 8:00am-8:00pm (TTY/TDD users: 711). Interpreter services are also available. or reach us by mail at:

AgeWell New York
Appeals and Grievances Department
1991 Marcus Avenue. Suite M201
Lake Success, NY 11042

Part D Appeal (Redetermination Request)

Redetermination Request Form [3]

Coverage Determination Form [4]

If your request for a Part D coverage determination was denied, you or your provider has the right to appeal our decision within 60 calendar days from the date of the notice of the denial.  Once we received your request, we must make a decision no later than 72 hours (for expedited requests) or 7 calendar days (for standard requests) from receipt of the request

You may initiate a Part D Appeal:

EnvisionRxOptions
2181 E. Aurora Rd., Suite 201
Twinsburg, OH 44087
Attn: Clinical Appeals