Grievances & Appeals

What is a grievance?

A type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

How to file a grievance

A grievance may be filed in writing or by calling our Member Services Department. The grievance must be submitted within sixty (60) days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than thirty (30) days after receiving your complaint. To submit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. You may also call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.

Asking for a fast grievance

You have the right to file an expedited grievance whenever we deny your request for an expedited decision about your request for a service, or, whenever we deny your request for an expedited decision about your appeal for a service. You also have the right to file an expedited grievance if you do not agree with our decision to extend the time needed to make a decision on your request for a service, or to consider your appeal for a service. We must decide within twenty-four (24) hours if our decision to deny or delay making an expedited decision puts your life or health at risk. We may extend the timeframe for deciding on a grievance by up to fourteen (14) days if you ask for the extension or are justified in request additional information and the delay is in your best interest. If we deny your grievance in whole or in part, our written decision will explain why we denied it and will tell you about any dispute resolution options you may have.

Quality of care issues

Quality of care issues may be filed in writing or by calling our Member Services department within sixty (60) days of the event or incident. You may also make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization, without making the complaint to us. If you wish, you can make your complaint about quality of care to us and to the Quality Improvement Organization at the same time.

Requests for Part D drugs and/or Part C medical care or services or payment

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or Part D prescription drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

Initial determination for coverage

Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want or about the amount we will pay for your drugs. You, your doctor, or your representative can do this.

What is a formulary exception?

A type of coverage determination that, if approved, allows you to get a drug that is not on your plan sponsor’s formulary (a formulary exception).

Asking for a “standard” or “fast” initial determination

When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines.

A standard coverage decision for providing coverage for the medical care you want means we will give you an answer within 14 calendar days after we receive your request for a medical item or service. A fast coverage decision means we will answer within 72 hours. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request.

A standard coverage determination for providing a decision about your prescription drug coverage means we will give you an answer within 72 hours after we receive your request. A fast coverage determination means we will answer within 24 hours.

Appeal to the plan

You have the right to ask us to reconsider – and perhaps change – a determination decision by making an appeal. Making an appeal means making another try to get the medical care or prescription drug coverage you want.

How to file your appeal

To start your appeal, you (or your representative or your doctor) must contact us. If you are asking for a standard appeal, make your standard appeal in writing by submitting a request. If you are asking for a fast appeal, make your appeal in writing or call us. You must make your request within 60 calendar days from the date on the written notice we sent to you to tell you our answer to your request for a coverage decision or coverage determination.

For more information on determination requests, appeals and grievances, please see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaint) in your Evidence of Coverage. You may also contact Member Services for more information.