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.