CareWell Appeals and Grievances
To view the formal Appeals and Grievance Processes, please review Chapter 9 of the Evidence of Coverage as applicable:
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. (Appointment of Representative Form) 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:
- Your name, address and telephone number
- Your HICN number (this is your Medicare number on the red, white and blue Medicare ID card)
- Name, address and telephone number of the individual being appointed
- Contain a statement that you are authorizing the representative to act on your behalf, and a statement authorizing disclosure of identifying information to the representative
- Signed and dated by you
- Signed and dated by the individual being appointed as your representative, and the individuals statement that they accept being your representative
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 M107 | 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 TTY/TDD 1-800-662-1220. You can also submit a complaint at Medicare.gov or call 1-800-Medicare.
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:
- Deny or limit a service request.
- Reduce or stop services you have been getting.
- Refuse to pay for services that you think should be covered.
You will get a letter from us when any of these actions occur. 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
You must submit your standard appeal request in writing to the address below.
If your expedited appeal request was filed verbally, written notice is not needed. For expedited appeals, we will call you with the decision. 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:
- Transfer the appeal to the timeframe for standard resolution.
- Make reasonable efforts to try to call you.
- Inform you in writing that you may file an expedited grievance about the denial of the expedited process.
- Inform you of the right to resubmit the request with a physician support indicating that applying the standard timeframe would seriously jeopardize your life or health
AgeWell New York must make its appeal 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 appeal determination no later than 60 calendar days from the date we receive the request.
To obtain an aggregate number of grievances, appeals and exceptions filed with the plan, please call us at 1-866-237-3210 (TTY/TDD 1-800-662-1220), Monday through Friday, 8:00am-8:00pm, or reach us by mail at:
AgeWell New York
Appeals and Grievances Department
1991 Marcus Avenue. Suite M107
Lake Success, NY 11042
Part D Appeal (Redetermination Request)
Coverage Determination Request Form
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:
- By calling 1-800-361-4542;
- Through Elixir website. Visit https://elixirsolutions.promptpa.com; or
- By filling out our Redetermination Request Form and faxing it back to 877-503-7231 or mailing your request to:
7385 Freedom Avenue NW
North Canton, OH 44720
Attn: Clinical Appeals