Member Resources

Nou bay anpil enpòtans a manm nou yo nan Solis Health Plans. Nou travay di pou asire tout manm nou yo satisfè avèk nou. Sepandan, si ou gen yon plent oswa yon preokipasyon, ou ka soumèt yon grievance. Yon grievance se yon plent ki eksprime insatisfaksyon ak nenpòt aspè nan operasyon, aktivite, oswa konpòtman yon plan sante Medicare, oswa founisè li yo.

Ou ka mande yon grievance akselere si:

Nou refize demann ou pou yon desizyon akselere sou òganizasyon/ kouvèti.
Nou refize demann ou pou yon revizyon akselere/ apèl Pati C ak/oswa redetermination/ apèl Pati D.
Ou pa dakò avèk desizyon nou pou pwolonje delè a pou fè yon desizyon òganizasyon/kouvèti oswa revizyon akselere/ apèl Pati C ak/oswa redetermination/ apèl Pati D.

Apelasyon
Yon apèl se aksyon ou oswa reprezantan otorize ou ka pran si ou pa dakò ak yon desizyon Solis Health Plans te pran sou yon Detèminasyon Òganizasyon. Lè nou fini revizyon an, nou pral bay ou desizyon nou an. Gen senk nivo ki swiv nan pwosesis apèl la:

Nivo 1: Revizyon pa plan sante a.
Nivo 2: Revizyon pa Entite Revizyon Endepandan (IRE).
Nivo 3: Odyans pa yon Jij Administratif (ALJ).
Nivo 4: Revizyon pa Konsèy Apèl Medicare (MAC).
Nivo 5: Revizyon pa yon Tribinal Distrik Federal.

Yon desizyon ka apèl nan nivo ki pi ba lè antite apèl ki pi ba bay yon desizyon ki pa favorab pou manm nan. Chak lèt desizyon ki pa favorab yo pral bay enstriksyon sou kijan pou ale nan nivo apèl ki vin apre a. Ou oswa reprezantan otorize ou ka ale nan premye nivo apèl la pa mande Solis Health Plans pou revize desizyon detèminasyon kouvèti ki pa favorab la.

Lè w ap soumèt yon Redetermination (Apèl Pati D) ekri, tanpri sonje ke si apèl ou a gen rapò ak yon desizyon nou te fè pou refize yon medikaman ki pa sou fòmilè nou an, preskiptè ou dwe endike ke tout medikaman sou nenpòt nivo fòmilè nou an pa ta osi efikas pou trete kondisyon ou kòm medikaman ki pa sou fòmilè a oswa ta ka domaje sante ou. Ou ka kontakte tou depatman Sèvis Manm nou an pou mande yon Fòm Demann Redetermination oswa wè fòm ki ka telechaje ki anba a.

Ki Jan Pou Soumèt yon Grievance ak/oswa Apèl
Ou oswa reprezantan otorize ou ka soumèt yon grievance ak Solis Health Plans pa pita pase 60 jou apre evènman an. Ou ka fè sa pa nenpòt nan fason sa yo:

Vèbalman:
Rele depatman Sèvis Manm Solis nan 1-844-447-6547, TTY 711.8 a.m. a 8 p.m.
Apr 1 - Sep 30: Lendi - Vandredi
Oct 1 - Mar 31: 7 jou nan semèn nan

Ekri:
Si ou prefere, ou ka telechaje yon kopi fòm lan anba a epi voye li pa faks oswa lapòs:

Nimewo faks: 833-615-9263
Adrès postal:
Solis Health Plans, Inc.
PO Box 524173
Miami, FL 33152

Fòm Grievance ak Apèl Si ou oswa reprezantan legal ou bezwen asistans pou prepare ak soumèt demann Redetermination ekri ou a, tanpri kontakte depatman Sèvis Manm Solis la e yon Reprezantan Sèvis Manm ap ede ou.Yon fwa demann lan resevwa pa Solis Health Plans, nou pral pran desizyon e bay avètisman sou desizyon nou an osi vit ke sante ou mande, men pa pi ta pase 72 èdtan pou demann akselere, oswa 7 jou kalandriye pou demann estanda. Si desizyon an pa favorab, ou oswa reprezantan otorize ou ka mande plis revizyon. Apre premye nivo apèl la, tout nivo apèl ki swiv yo ap revize pa yon antite ki gen kontra avèk Pwogram Medicare la, oswa sistèm tribinal federal la. Sa ap ede asire yon desizyon jis ak san patipri.Ou ka tou soumèt yon plent sou sit Fòm Detèminasyon Kouvèti, Fòm Redetermination Refizyon Medikaman Medicare

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

Pou mande yon Otorizasyon Sèvis, tanpri telechaje fòm lan isit la.

Jèsyon Itilizasyon (UM) se yon pwosesis pou jere pri swen sante yo atravè teknik desizyon sou apwopriye swen nan chak ka. Nan pwosesis UM, Solis Health Plans travay ansanm ak founisè swen prensipal ou pou planifye yon swen pèsonalize ki apwopriye e ki tou ekonomik. Materyèl ki bay pa Solis Health Plans yo se direktiv ki itilize pou otorize, modifye oswa refize swen pou moun ki gen maladi oswa kondisyon ki sanble. Swen ak tretman espesifik yo ka varye selon bezwen endividyèl yo ak avantaj yo kouvri anba kontra plan ou.

Direktiv klinik ki apwouve pa Solis Health Plans yo enkli direktiv klinik ki devlope entènman, kritè InterQual, MCG (Milliman Care Guidelines), rapò teknoloji Hayes, Detèminasyon Kouvèti Nasyonal (NCD) ak lòt resous ki baze sou prèv. Direktiv klinik yo evalye e mete ajou omwen chak ane e yo disponib pou manm ak founisè yo.

Direktiv klinik yo konplèks e yo fèt pou itilizasyon pwofesyonèl sante. Yo pa fèt pou bay konsèy medikal oswa swen medikal. Konsèy medikal ak swen yo dwe diskite ak founisè tretman ou oswa founisè swen prensipal ou. Jan sa endike nan avètisman egzònérasyon ki anba a, kouvèti a sijè a tèm ak kondisyon plan avantaj manm yo ak lwa eta ak federal yo. Pou konfime kouvèti avantaj yo oswa pou mande yon kopi direktiv klinik yo itilize pou sipòte desizyon sou bezwen medikal, kontakte Sèvis pou Manm yo ap rele nan 844-447-6547.

Avètisman Egzònérasyon: Direktiv klinik yo devlope e adopte pou etabli kritè klinik ki baze sou prèv pou desizyon jèsyon itilizasyon. Solis Health Plans ka delege desizyon jèsyon itilizasyon pou sèten sèvis a delegasyon twazyèm pati, ki ka devlope ak adopte pwòp kritè klinik yo. Direktiv klinik yo aplike pou sèten plan. Direktiv klinik yo aplike pou manm ki anrejistre nan plan Medicare Advantage sèlman si pa gen okenn kritè etabli pou sèvis espesifik nan yon detèminasyon kouvèti nasyonal (NCD) Centers for Medicare and Medicaid (CMS) oswa nan yon detèminasyon kouvèti lokal (LCD) nan dat yon demann otorizasyon anvan. Sèvis yo sijè a tèm, kondisyon ak limitasyon politik manm yo ak lwa eta ak federal ki aplikab yo. Tanpri konsilte dokiman politik manm yo (egzanp, Sètifika / Prèv Kouvèti, Pwogram Avantaj) oswa kontakte Solis Health Plans nan 844-447-6547. *Enstiti Medsin, Komite sou Jèsyon Itilizasyon pa Twazyèm Pati: Kontwole Pri, Chanje Swen Pasyan? Wòl Jèsyon Itilizasyon. Nan Gray, B.H., ak Field, M.J., eds. Washington, National Academy Press, 1989.

Determining Levels of Care anDetèminasyon Nivo Swen ak Kouvèti
‍Evalyasyon swen ka fèt anvan ou resevwa swen, sa yo rele Revizyon Previzyon Sèvis, pandan w ap resevwa swen, sa yo rele Revizyon Konstan, oswa apre ou fin resevwa swen, sa yo rele Revizyon Retrospektif.

Revizyon Konstan
Nou ka evalye swen ou pandan ou nan lopital oswa ap resevwa tretman anbisoutwa. Objektif nou se ede asire ke moun nan resevwa nivo apwopriye swen, nan moman apwopriye, nan plas apwopriye ak yon pri rezonab. Atravè revizyon konstan, nou detèmine si plan moun nan kouvri tretman ki ap evalye a.

Revizyon konstan enkli:

Koleksyon Enfòmasyon: Ranmase enfòmasyon nan ekip swen sou kondisyon ak pwogrè pasyan an.
Detèminasyon Kouvèti: Baz sou enfòmasyon ranmase.
Kominikasyon: Enfòme tout moun ki angaje nan swen pasyan an sou detèminasyon kouvèti a.
Planifikasyon Sòti ak Swen Kontinyèl: Idantifye yon plan ki enkli sòti ak swen kontinyèl osi vit ke posib pandan sejou a.
Evalyasyon Kontinyèl: Evalye plan an pandan sejou a.
Referans: Idantifye manm pou referans nan pwogram espesyalize, ki enkli jèsyon ka oswa jèsyon maladi.

Revizyon Retrospektif se pwosesis pou detèmine kouvèti apre swen an te bay.

Revizyon retrospektif enkli:

Konfimasyon Elijibilite: Konfime elijibilite manm nan ak disponiblite avantaj yo.
Analiz Done Pasyan: Analize done swen pasyan an pou sipòte pwosesis detèminasyon kouvèti a.

Revizyon retrospektif disponib lè egzijans pre-sètifikasyon ak notifikasyon yo te respekte nan moman sèvis la te bay, men dat sèvis yo pa koresponn ak reklamasyon an. Li pa disponib pou sèvis elektif anbisoutwa oswa inpatient ki te mande pre-sètifikasyon e pre-sètifikasyon an pa te fèt anvan bay sèvis la. Si sèvis inpatient te mande pre-sètifikasyon men li te bay kòm yon sèvis ijans, notifikasyon yo bezwen fèt nan yon jou travay depi dat admisyon an.
Kijan pou mande yon kouvèti espesifik?

How to ask for specific coverage?
Ou gen dwa mande Solis Health Plans pou peye pou atik oswa sèvis ou kwè yo ta dwe kouvri, sa yo rele desizyon kouvèti.

Si ou se yon manm Medicare, sa a rele yon demann “detèminasyon òganizasyon.” Yon detèminasyon òganizasyon (ki rele tou desizyon kouvèti) se yon desizyon Solis Health Plans pran sou avantaj ou ak kouvèti ak si n ap peye pou sèvis medikal ke ou oswa doktè ou te mande. Ou ka kontakte nou tou pou mande yon desizyon kouvèti anvan ou resevwa sèten sèvis medikal. Ou ka vle mande nou yon desizyon kouvèti davans si doktè ou pa sèten si nou pral kouvri yon sèvis medikal patikilye oswa si doktè ou refize pou bay ou yon swen medikal ou kwè ou bezwen. Ou, reprezantan ou oswa doktè ou ka mande nou yon desizyon kouvèti pa rele nou, ekri nou oswa voye yon faks.

Kijan pou fè yon demann?
Rele gratis nan 1-844-447-6547. Ou ka rele nou soti lendi rive vandredi, soti 8 a.m. rive 8 p.m. (lè estanda lès) ant 1 avril ak 30 septanm, oswa chak jou nan semèn nan soti 8 a.m. rive 8 p.m. soti 1 oktòb rive 31 mas. Si ou rive nan sistèm otomatik nou an deyò lè oswa nan jou ferye, kite non ou ak nimewo telefòn ou, e nou pral retounen apèl la nan fen pwochen jou travay la. Sèvis pou Manm yo gen tou sèvis entèprèt gratis pou moun ki pa natif natal. TTY 711 Apèl nan nimewo sa a yo gratis.

Nimewo sa a bezwen ekip telefòn espesyal epi se sèlman pou moun ki gen difikilte odyo oswa pale.

Faks: 1-833-210-8141
Kontakte nou pa faks si ou gen yon demann kouvèti ijans.

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

Konbyen tan li pral pran pou jwenn yon desizyon sou kouvèti?
Nou pral sèvi ak dat limit "estanda" sof si nou te dakò pou sèvi ak dat limit "akselere" (rapid) yo.

Desizyon kouvèti estanda
Yon desizyon kouvèti estanda vle di nou pral bay yon repons nan 14 jou apre nou resevwa demann ou an.

Desizyon kouvèti ekspedite (rapid)

Si ou kwè sante ou ta ka afekte gravman oswa ou ka pèdi kapasite ou pou fonksyone pandan w ap tann 14 jou estanda pou yon desizyon, ou ka mande yon desizyon “ekspedite” (rapid).

Nou pral bay yon repons nan 72 èdtan apre nou resevwa demann ou pou yon desizyon rapid.

Pou jwenn yon desizyon rapid, ou dwe satisfè de kondisyon:

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.

Avètisman Tanpèt: Hurricane Milton [Learn More]

Storm Advisory: Hurricane Milton [Learn More]

Resous Manm yo

Nou kontan ou chwazi pou rantre nan Solis Health Plans - ou se yon etap pi pre sante optimal. Isit la, ou pral jwenn dokiman plan enpòtan ki ede w jere plan sante ou.

KOUMAN POU ITILIZE GID BENEFIS OU

Nan Solis, asire ke manm nou yo konprann benefis yo ak kijan pou yo itilize yo se youn nan priyorite nou yo. Pou sa, nou devlope yon gid itil ki dekri kijan manm yo ka jwenn plis itilizasyon nan zouti nou bay yo.

Fason pou itilize Gid Avantaj ou yo

ESPACIO PARA COMPONENTE

DWA, DEVWA, & AVIS KONFIDANSYALITE

Dwa ak Responsablite Manm

Avis sou Politik Konfidansyalite

Lis Ekipman Medikal Dirab (DME) Solis kouvri menm DME ak Original Medicare.

2024 Lis DME Prefere

Ou pral kite
Solis Health Plans

Ou pral redireksyonne nan

Resous Manm yo

Nou kontan ou chwazi pou rantre nan Solis Health Plans - ou se yon etap pi pre sante optimal. Isit la, ou pral jwenn dokiman plan enpòtan ki ede w jere plan sante ou.

KOUMAN POU ITILIZE GID BENEFIS OU

Nan Solis, asire ke manm nou yo konprann benefis yo ak kijan pou yo itilize yo se youn nan priyorite nou yo. Pou sa, nou devlope yon gid itil ki dekri kijan manm yo ka jwenn plis itilizasyon nan zouti nou bay yo.

Fason pou itilize Gid Avantaj ou yo

ESPACIO PARA COMPONENTE

DWA, DEVWA, & AVIS KONFIDANSYALITE

Dwa ak Responsablite Manm

Avis sou Politik Konfidansyalite

Lis Ekipman Medikal Dirab (DME) Solis kouvri menm DME ak Original Medicare.

2024 Lis DME Prefere

Grievances

Jèsyon Ka

Jèsyon Itilizasyon

Appoint a Representative

Make Plan Changes

Ou pral kiteSolis Health Plans

Ou pral redireksyonne nan

Ou pral kite
Solis Health Plans