Member Resources

Our members are very important to Solis Health Plans. We work hard to ensure all our members are satisfied with us. However, if you do have a complaint or concern, you may file a grievance. A grievance is a complaint expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Medicare health plan, or its providers.

You may request an expedited grievance if:

We deny your request for an expedited organization/coverage determination.
We deny your request for an expedited reconsideration/Part C appeal and/or redetermination/Part D appeal.
You disagree with our decision to extend the timeframe to make an initial organization/coverage determination or expedited reconsideration/Part C appeal and/or redetermination/Part D appeal.

Appeals
An appeal is the action you or your authorized representative can take if you disagree with a decision Solis Health Plans has made on an Organization Determination. When we have completed the review, we will provide you our decision. There are five successive levels to the appeals process:

Level 1: Reconsideration by the health plan.
Level 2: Review by the Independent Review Entity (IRE).
Level 3: Hearing by an Administrative Law Judge (ALJ).
Level 4: Review by the Medicare Appeals Council (MAC).
Level 5: Review by a Federal District Court.

A decision may be appealed to the next level when the lower appeal entity issues a decision that is unfavorable to the member. Each unfavorable decision letter will provide instructions on how to move to the next level of appeal. You or your authorized representative can go on to the first level of appeal by requesting Solis Health Plans to review the unfavorable coverage determination decision.

When filing a written Redetermination (Part D Appeal), please note that if your appeal relates to a decision by us to deny a drug that is not on our formulary, your prescriber must indicate that all the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health. You may also contact our Member Services department to request a Redetermination Request Form or see the downloadable form below.

How To File a Grievance and/or Appeal
You or your authorized representative can file a grievance with Solis Health Plans no later than 60 days after the occurrence. You can do so by any of the following ways:

Verbally:
Call Solis Member Services department at 844-447-6547 (TTY: 711). 
8 a.m. to 8 p.m.
Apr 1 - Sep 30: Monday - Friday 
Oct 1 - Mar 31: 7 days a week

In writing:
If you prefer, you can download a copy of the form below and send it via fax or mail:

Fax number: 833-615-9263
Mailing address:
Solis Health Plans, Inc.
PO Box 524173
Miami, FL 33152

You can also file a complaint directly on the CMS website.‍

Grievance and Appeals Form

Download

‍‍If you or your legal representative requires assistance in preparing and submitting your written Redetermination request, please contact the Solis Member Services department and a Member Services Representative will assist you.

Once the request is received by Solis Health Plans, we will decide and provide notice of our decision as quickly as your health requires, but no later than 72 hours for expedited requests, or 7 calendar days for standard requests. If the decision is unfavorable, you or your authorized representative can request further review. After the first level of appeal, all following levels of appeal will be reviewed by an entity that is contracted with the Medicare Program, or the federal court system. This will help ensure a fair and impartial decision.

You can also file a complaint in the CMS website.

Coverage Determination Form

Download

Redetermination of Medicare Prescription Drug Denial Form

Download

Is Case Management right for you?

You may benefit from Case Management services if you have any of the following conditions:

If you have more than one of these conditions: Heart Disease, Diabetes, Asthma, or Chronic Obstructive Pulmonary Disease.
If you have recently been discharged from an inpatient hospital setting.
If you have had a psychiatric admission or if you have been diagnosed with any of these illnesses: Bipolar Disorder, Major Depressive Disorder, Paranoid Disorder, Schizophrenia, or schizoaffective disorder.
If you take 8 or more different medications.
If you struggle with alcohol, opioids, or other recreational drugs.

Who can access Case Management services:

Members who are enrolled in Solis and live in the service area of Miami-Dade, Broward, Palm Beach, Hillsborough, Pinellas, and Polk counties may be eligible to participate in Solis’ Case Management Services.

Who can make a referral to Case Management?

Physician offices.
Case Managers/Discharge Planners.
Social Workers.
Medicaid or Social Security Case Workers.
Customer Service Representatives.
A Member or their Responsible Party.

How can Case Managers help you?

A Case Manager:

Works to improve your quality of life, functional status and overall health.
Helps you navigate the complex care system.
Helps you understand your individual health care benefits so that you can get the most from your plan.
Serves as an educator when you have questions regarding your health care.
Helps you access the community resource you need to live better.
Supports and reinforces your recommended treatments and therapies.

Our Case Managers believe in taking a holistic approach to health care. They will work with you to form a personalized care plan to help you establish your priorities and achieve your maximum health potential. A Solis Case Manager will also collaborate with you, your care team, providers and in-network specialists to ensure you receive high-quality care.

Case Management Facts:

You can stop Case Management at any time.
You don't need a referral from a doctor to participate in Case Management.

To get started: Call Care Management directly at (833) 896-3762.

To request for Service Authorization, please download the form here.

Utilization management (UM) is a process to manage health care costs through decision-making techniques on a case-by-case assessment of the appropriateness of care. Through the UM process, Solis Health Plans works together with your primary care provider to plan individualized care that is appropriate as well as cost effective. The materials provided to you by Solis Health Plans are guidelines used to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your plan’s contract.

Clinical guidelines approved by Solis Health Plans include internally developed clinical guidelines, InterQual criteria, MCG (Milliman Care Guidelines), Hayes technology reports, National Coverage Determinations (NCD) and other evidence-based resources. Clinical guidelines are evaluated and updated at least annually and are available to both members and providers.

Clinical guidelines are complex and intended for use by healthcare professionals. They are not intended to provide medical advice or medical care. Medical advice and care should be discussed with the treating provider or primary care provider. As noted in the disclaimer below, coverage is subject to the terms and conditions of your benefit plan and state and federal law. To confirm benefit coverage or to request a copy of a clinical guideline used to support medical necessity decisions, please contact Member Services by calling 844-447-6547.

Disclaimer: Clinical guidelines are developed and adopted to establish evidence-based clinical criteria for utilization management decisions. Solis Health Plans may delegate utilization management decisions of certain services to third-party delegates, who may develop and adopt their own clinical criteria. Clinical guidelines are applicable to certain plans. Clinical guidelines are applicable to members enrolled in Medicare Advantage plans only if there are no criteria established for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of a prior authorization request. Services are subject to the terms, conditions, limitations of a member’s policy and applicable state and federal law. Please reference the member’s policy documents (e.g., Certificate/Evidence of Coverage, Schedule of Benefits) or contact Solis Health Plans at 844-447-6547. Institute of Medicine Committee on Utilization Management by Third Parties: Controlling Costs, Changing Patient Care? The Role of Utilization Management. In Gray, B.H., and Field, M.J., eds. Washington, National Academy Press, 1989.

Determining Levels of Care and Coverage
‍Evaluation of care may be performed prior to receiving the care, also known as Preservice, while you are receiving the care, also known as Concurrent review, or after you have received the care, also known as Retrospective Review.

Concurrent Review
We may evaluate your care while you are in the hospital or receiving outpatient treatment. We aim to help make sure the person gets the right level of care, at the right time, in the right location, and at a reasonable cost. Through concurrent review, we determine if the person’s plan covers the treatment that is under review.

Concurrent review process includes:

Collecting information from the care team about the person’s condition and progress.
Determining coverage based on this information.
Informing everyone involved in the patient’s care about the coverage determination.
Identifying a plan that includes discharge and continuing care as early as possible within the stay.
Ongoing assessment of the plan during the stay.
Identifying members for referral to specialty programs inclusive of case management or disease management. Concurrent review may be done by phone, fax, or on-site at the facility.

Retrospective review is the process of determining coverage after treatment has been given.

Retrospective review process includes:

Confirming a member’s eligibility and availability of benefits.
Analyzing patient care data to support the coverage determination process

Retrospective review is available when precertification and notification requirements were met at the time the service was provided, but the dates of service do not match the submitted claim. Retrospective review is not available when claims are for elective ambulatory or inpatient services that required precertification and precertification did not occur before providing the service. If inpatient service required precertification but was rendered as an emergency service, notification is required within one business day of the admission date.

Frequently Asked Questions (FAQs)

How to ask for specific coverage?
You have the right to ask Solis Health Plans to pay for items or services you think should be covered, also called a coverage decision.

If you are a Medicare member, this is called a request for "organization determination.” An organization determination (referred to here as a coverage decision) is a decision Solis Health Plans makes about your benefits and coverage and whether we will pay for the medical services you or your doctor have requested. You can also contact us to ask for a coverage decision before you receive certain medical services. You might want to ask us to make a coverage decision beforehand if your doctor is unsure whether we will cover a particular medical service or if your doctor refuses to provide medical care you think you need. You, your representative, or your doctor can ask us for a coverage decision by calling, writing, or faxing your request to us.

How to make a request?
Make a free call to 1-844-447-6547. You can call us Monday through Friday, from 8 a.m. - 8 p.m. (Eastern Standard Time) between April 1st -September 30th or seven days a week from 8 a.m. – 8 p.m. from October 1st to March 31st. If you reach our automated system after hours or on holidays, please leave your name and telephone number, and we’ll call you back by the end of the next business day. Member Services also has free language interpreter services available for non-English speakers. TTY 711 Calls to this number are free.

This number requires special telephone equipment and is only for people who have difficulties hearing or speaking.

Fax: 1-833-210-8141
Contact us by fax should you have an expedited coverage request.

‍Write:
Solis Health Plans
9250 NW 36th St., Suite 400
Doral, FL 33178.

How long will it take to get a coverage decision?
We will use “standard” deadlines unless we have agreed to use the “expedited” (fast) deadlines.

Standard coverage decision
A standard coverage decision means we will give you an answer within 14 days of receiving your request.

Expedited (fast) coverage decision

If you think your health could be seriously harmed or that you could lose your ability to function by waiting the standard 14 days for a decision, you can ask for an “expedited” (fast) decision.

We will give you an answer within 72 hours after we receive your request for a fast coverage decision.

To get a fast coverage decision, you must meet two requirements:

You must be asking for coverage for medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care, you have already received.)
You must make a fast decision because using the standard deadlines could cause serious harm to your health or hurt your ability to function.

How to request an expedited (fast) coverage decision
If your doctor tells Solis Health Plans that your health requires a “fast coverage decision” also known as an expedited request, we will automatically agree to give you a fast coverage decision.

If you ask for a fast coverage decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision.

If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so and we will use the standard deadlines instead.

Extended time for a decision
We can take up to 14 more calendar days to make either a standard or fast decision if you ask for more time or if we need information, such as medical records from out-of-network providers, that may benefit you. This is called an extension. If we decide to take extra days to make the decision, we will tell you in writing.

If you believe we should not take extra days, you can file a “fast complaint”, also known as an expedited grievance, about our decision to take extra days. When you file an expedited grievance, we will give you an answer to your complaint within 24 hours.

If we do not give you our answer within the standard or fast time (or if there is an extension at the end of that period), you have the right to appeal. You also have the right to file an appeal if you disagree with our coverage decision.

When we tell you we will not cover a service?
In some cases, we might decide a service is not covered or is no longer covered by your plan. If we say “no” to part or all of what you requested, we will send you a detailed written explanation as to why we said “no” and instructions on how to appeal our decision.

When is approval required before receiving an item or service?
For some types of items or services, your doctor may need to get approval in advance from our plan (this is called getting "prior authorization"). Those services that require advance approval are included in your Evidence of Coverage.

In order for Solis to process a Grievance or/and Appeal request from someone other than you (the member), your physician, your prescribing physician (Part D), or other prescriber (Part D), we must have authorization from you. You may appoint any individual as your representative by sending us an Appointment of Representative form signed by both you and the representative. A representative who is appointed by the court or who is acting in accordance with state law may also file a request for you after sending us the legal representative form.

You will not need to complete an Appointment of Representative Form if you provide an equivalent written notice or other legal representation document with your request.

How to Appoint a Representative

Medicare rules allow you to appoint a representative in the grievance and/or appeals process. Members can contact their local Social Security Office, get help from the local Agency on Aging, or the Solis Member Services department.
You may appoint any individual (such as a relative, friend, advocate, attorney, physician, and/or other prescriber, or an employee of a pharmacy, charity, or other secondary payer) to act as your legal representative.
The appointment is considered valid for one year from the date that the Appointment of Representative Form is signed by both you (the member) and your legal representative.
The legal representative has the same rights as the member to the request. They can submit evidence on your behalf.
The legal representative may have access to personal information about you.
To appoint a legal representative, you must fill out the Appointment of Representative Form (Form CMS-1696).

Instructions for Submitting an Appointment of Representative Form

Members may return the completed form by mail or by fax to:Fax number: 1-833-615-9263

Mailing Address:
Solis Health Plans
Attn: Grievance and Appeals department
PO Box 524173
Miami, FL 33152

If you have any questions or concerns, please contact our Member Services department at 1-844-447-6547, TTY 711, from 8 a.m. to 8 p.m. seven days a week from Oct. 1 – March 31 and 8 a.m. to 8 p.m. Monday-Friday from April 1 - Sept. 30.

Easy Ways to Enroll

A Personalized Visit.
We want to make sure you are well informed about all the benefits that are made available to you. We have an expert team of certified Sales Associates, who are ready to visit you and help answer any questions you may have.

To schedule an appointment with a certified Solis Sales Associate, please contact us at: (844) 447-6547.

Hours of Operation:
8 a.m. to 8 p.m. seven days a week from Oct. 1 – March 31 8 a.m. to 8 p.m. Monday-Friday from April 1 - Sept. 30
Download the Enrollment Form.Our enrollment application may be accessed below: 2024 Enrollment Application.

Our Solis website will guide you in finding answers to any of the health plan questions you may have.

Please print and send your completed enrollment form to:
Solis Health Plans, Inc. (HMO)
Member Services Department
9250 NW 36TH Street, Suite 400
Doral, FL 33178
Medicare Beneficiaries may also enroll in Solis Health Plans through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

Disenrollment
(Solis Health Plans, Inc. (HMO), upon receipt of a disenrollment request, will send you a disenrollment acknowledgement letter within ten (10) calendar days. Once CMS confirms the disenrollment, the plan will send you a disenrollment confirmation letter. These notices include explanations of restrictions during the lock-in period and the effective date of the disenrollment. You must continue to use the plan until the disenrollment is effective.

(If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment. If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. ("Creditable" coverage means the coverage is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage.) See Chapter 6, Section 9 of your EOC for more information about the late enrollment penalty.

As a member of the plan, it is your responsibility to notify us if you have moved out of the plan service area. If you are not sure if you moved out of our area, please contact the Member Services Department (844) 447-6547. TTY users should call 711. We are open October 1 – March 31: 7 days a week, from 8:00 a.m. to 8:00 p.m., Eastern Standard Time and April 1 – September 30: Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Standard.

Storm Advisory: Hurricane Helene [Learn More]

Storm Advisory: Hurricane Milton [Learn More]

Member Resources

We are happy you chose to join Solis Health Plans - you are one step closer to optimal health. Here, you'll find important plan documents that help you manage your health plan.

How to Use your Benefits Guide

At Solis, ensuring that our members understand their benefits and how they can use them is of the utmost importance to us. Because of that, we developed a helpful guide that outlines how members can get the most use out of the tools we provide to them.

How to Use your Benefits Guide

ESPACIO PARA COMPONENTE

Rights, Duties, & Privacy Notice

Member Right & Responsibilities

Notice of Privacy Policy

Durable Medical Equipment (DME) List Solis covers the same DME as Original Medicare.

2024 Preferred DME List

You are now leaving
Solis Health Plans

You will be redirected to

Member Resources

We are happy you chose to join Solis Health Plans - you are one step closer to optimal health. Here, you'll find important plan documents that help you manage your health plan.

How to Use your Benefits Guide

At Solis, ensuring that our members understand their benefits and how they can use them is of the utmost importance to us. Because of that, we developed a helpful guide that outlines how members can get the most use out of the tools we provide to them.

How to Use your Benefits Guide

ESPACIO PARA COMPONENTE

Rights, Duties, & Privacy Notice

Member Right & Responsibilities

Notice of Privacy Policy

Durable Medical Equipment (DME) List Solis covers the same DME as Original Medicare.

2024 Preferred DME List

Grievance & Appeals

Case Management

Utilization Management

Appoint a Representative

Make Plan Changes

You are now leaving Solis Health Plans

You will be redirected to

You are now leaving
Solis Health Plans