Our Appeals & Grievance Process

The following procedures for appeals and grievances must be followed by your Medicare Advantage health plan in identifying, tracking, resolving and reporting all activity related to an appeal or grievance.

Member Appeals

Who can file an Appeal?

An appeal may be filed by any of the following:

• You may file an appeal.
• Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
• Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I [your name] appoint [name of representative] to act as my representative in requesting an appeal from your Medicare Advantage health plan and/or CMS regarding the denial or discontinuation of medical services."
• You must sign and date the statement.
• Your representative must also sign and date this statement.
• You must include this signed statement with your appeal.

What is an Appeal?

An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your Medicare Advantage health plan pays or will pay for a service or the amount you must pay for a service.

When can an Appeal be filed?

You may file an appeal within sixty (60) calendar days of the date of the notice of the initial organization determination. For example, you may file an appeal for any of the following reasons:

• your Medicare Advantage health plan refuses to cover or pay for services you think your Medicare Advantage health plan should cover.
• your Medicare Advantage health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
• your Medicare Advantage health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
• If you think that your Medicare Advantage health plan is stopping your coverage too soon.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

Where can an Appeal be filed?

An appeal may be filed in writing directly to us or contacting Customer Service at the telephone number (or the TTY number for the hearing impaired) listed in the Summary of Benefits 8 a.m. to 8 p.m., local time 7 days a week. You may also contact Customer Service and request the facsimile number for Appeals and Grievances.

Why file an Appeal?

You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your Medicare Advantage health plan paid for a service.

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize:

• your life or health, or
• your ability to regain maximum function.

If your Medicare Advantage health plan or your Primary Care Physician, decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan or your Primary Care Physician will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request.

Member Grievances

Who can file a Grievance?

A grievance may be filed by any of the following:

• You may file a grievance.
• Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:
• Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I [your name] appoint [name of representative] to act as my representative in requesting a grievance from your Medicare Advantage health plan and/or CMS regarding the denial or discontinuation of medical services."
• You must sign and date the statement.
• Your representative must also sign and date this statement.
• You must include this signed statement with your grievance.

What is a Grievance?

A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your Medicare Advantage health plan or a Contracting Medical Provider. For example, you would file a grievance: if you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office.

When can a Grievance be filed?

You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance. There is no filing limit for complaints concerning quality of care. Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

Expedited Grievance

You have the right to request a fast review or expedited grievance if you disagree with your Medicare Advantage health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your Medicare Advantage health plan's decision to process your expedited request as a standard request. In such cases, your Medicare Advantage health plan will acknowledge your grievance within twenty-four (24) hours of receipt and notify you in writing of your Medicare Advantage health plan's conclusion within three (3) calendar days.

Where can a Grievance be filed?

A grievance may be filed in writing directly to us or contacting Customer Service at the telephone number (or the TTY number for the hearing impaired) listed in the Summary of Benefits 8 a.m. to 8 p.m., local time, 7 days a week. You may also contact Customer Service and request the facsimile number for Appeals and Grievances.

Why file a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.