Member Resources

At Solis Health Plans, our members are very important to us, and we work hard to ensure their satisfaction.

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:

By phone:
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?

All members who are enrolled in Solis 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 Case Management directly at (833) 896-3762.

‍

How We Support Your Care

‍At Solis Health Plans, we use a process called Utilization Management (UM) to help make sure you get the right care at the right time. This means we work closely with your primary care provider to review treatments, tests, and services so that your care is both appropriate for your needs and cost-effective.

Our review is based on trusted medical guidelines, such as InterQual, MCG (Milliman Care Guidelines), Hayes technology reports, and national coverage standards, along with guidelines developed by Solis Health Plans. These guidelines are reviewed and updated regularly to stay current with the latest medical evidence.

It’s important to know:

The guidelines are meant to help your care team make decisions about coverage—they are not medical advice.
Your doctor is always the one who provides your medical care.
Coverage depends on your individual health needs, your plan benefits, and state and federal law.

If you’d like a copy of the clinical guideline used for a decision about your care, or if you want to confirm what your plan covers, you can call Member Services at 844-447-6547 (TTY: 711). We’ll be happy to help.

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?
Phone: 844-447-6547 (TTY: 711)
You can call us Monday through Friday, from 8 a.m. - 8 p.m. 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.

Mail:
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 7 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.

Service for Authorization Form

Download

If you want someone else to help you with a Medicare grievance or appeal request, Solis needs your authorization before we can process it. This applies if the request comes from someone other than:

You (the member)
Your physician
Your prescribing physician (for Part D)
Another prescriber (for Part D)

Appointing a Representative
You can appoint any individual to act on your behalf by submitting an Appointment of Representative form signed by both you and your chosen representative.
‍
A representative who has been appointed by the court, or is acting in accordance with state law, may also file a grievance or appeal for you. In this case, they must send us the legal representative form.

Other Options for Authorization
You do not have to use the official Appointment of Representative form if you provide another type of equivalent written notice or legal document showing that person is authorized to represent you.

How to Appoint a Representative

Medicare rules allow you to appoint a representative to help with the grievance and/or appeals process. You can get help from your local Social Security Office, your local Agency on Aging, or by calling Solis Member Services.
The appointment is valid for one year from the date the Appointment of Representative Form (Form CMS-1696) is signed by both you (the member) and your chosen representative.
Once appointed, your representative has the same rights as you in the grievance or appeal process. They can submit evidence and communicate with Solis on your behalf.
Appointing a representative also gives them access to your personal health information related to the grievance or appeal.
To appoint a representative, complete the Appointment of Representative Form (Form CMS-1696) and submit it to Solis.

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
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 in Solis Health Plans

Schedule a Personalized Visit
We want you to feel confident about your Medicare coverage. Our team of certified Solis Sales Associates is ready to meet with you in person, explain your options, and answer any questions about your benefits.

To schedule an appointment, call us at (844) 447-6547.

Hours of Operation:
‍
October 1 – March 31: 7 days a week, 8 a.m. to 8 p.m.
‍April 1 – September 30: Monday – Friday, 8 a.m. to 8 p.m.
Download the Enrollment Form

You can easily download the 2026 Enrollment Application and complete it at your convenience.

Our website also provides helpful resources to guide you through the Medicare enrollment process and answer common health plan questions.

Please print and send your completed enrollment form to:
Solis Health Plans, Inc.
Attn: Enrollment 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 www.medicare.gov.

Disenrollment
You may disenroll from the plan during a valid election period by mailing, hand delivering, or faxing a signed and dated written notice or form to the plan. If the individual is unable to sign the disenrollment request, their authorized representative must do so.

Fax: 305-675-0933

Mailing Address:
Solis Health Plans, Inc.
Attn: Enrollment Department
9250 NW 36THStreet, Suite 400
Doral, FL33178

When you send us a disenrollment request, Solis Health Plans, Inc. (HMO) will send you an acknowledgement letter within 10 calendar days. After Medicare (CMS) confirms your disenrollment, you’ll receive a confirmation letter from us. This notice will explain the effective date of your disenrollment and any restrictions that may apply during the lock-in period. Until that date, you must continue using your Solis plan.

If you move to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may automatically place you in one—unless you’ve opted out of automatic enrollment. If you choose to go without prescription drug coverage and do not have other creditable coverage (coverage that is expected to pay at least as much as Medicare’s standard plan), you may have to pay a late enrollment penalty if you join a drug plan later.

For more information, see Chapter 6, Section 9 of your Evidence of Coverage (EOC).As a Solis member, it is your responsibility to let us know if you move outside of our service area. If you’re unsure whether your new address is within coverage, please call Solis Member Services at (844) 447-6547 (TTY 711).

Disenrollment Form

Download

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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.

Loading...

If you would like a paper copy of any of these materials, please call us at 844-516-0475 (TTY: 711).

2025

✓ 2026

At Solis Health Plans, we want to make sure that our members have the guidance they need to make the best decisions for their care.

Below, we provide important documents that you may need as a Solis Health Plans member.

Member Rights & Responsibilities

Notice of Privacy Policy

Request for Service Authorization

OTC Catalog

Case Management Referral Form

Durable Medical Equipment (DME) List

Medication Order Form

Appointment of Representative Form

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.

Loading...

If you would like a paper copy of any of these materials, please call us at 844-516-0475 (TTY: 711).

2025

✓ 2026

At Solis Health Plans, we want to make sure that our members have the guidance they need to make the best decisions for their care. Below, we provide important documents that you may need as a Solis Health Plans member.

Member Rights & Responsibilities

Notice of Privacy Policy

Request for Service Authorization

OTC Catalog

Case Management Referral Form

Durable Medical Equipment (DME) List

Medication Order Form

Appointment of Representative Form

Grievance & Appeals

Case Management

Utilization Management

Appoint a Representative

Make Plan Changes

You are now leaving Solis Health Plans

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At Solis Health Plans, we want to make sure that our members have the guidance they need to make the best decisions for their care.

Below, we provide important documents that you may need as a Solis Health Plans member.

You are now leaving
Solis Health Plans