Medicare appeals and grievances

If you have an issue, we’ll work hard to resolve your complaint or grievance in a way that’s stress-free and easy for you. You can see a total number of grievances , appeals , and exceptions filed with our plan. See the contact information above.

How you file a complaint depends on what your complaint is about. Details on the applicable notices and forms are available below (including English and Spanish versions of the standardized notices and forms). You, your representative, or your doctor must ask for an appeal from your plan within days from the date of the coverage determination. Care or a contracted provider.

Monday through Friday. For information about your Part D prescription drugs, click here. Appeals and grievances are the two types of complaints you can file.

For more information on coverage determinations, including exceptions, grievances , and appeals processes, please see the Evidence of Coverage for your plan. Grievance Process Endnotes. For Prime (HMO-POS), Flex (RPPO), Select (LPPO), Value Plus (HMO), and Focus DC (HMO SNP) plans, look at Chapter of the Evidence of Coverage.

Your health plan must follow strict rules for how we identify, track, resolve and report all appeals and grievances. Medical grievances. Sometimes you might need a formal process for dealing with a problem you are having as a member of our plan.

Expedited grievances will be answered within hours including Part B drugs. Also, the Evidence of Coverage (EOC) includes more details about grievances , coverage determinations, appeals procedures, and exceptions in Chapter and your rights and responsibilities upon disenrollment are listed in Chapter 8. If you’re concerned about the quality of care you’ve receive you may also file a complaint with Island Peer Review Organization (IPRO), the State’s Quality Improvement Organizations, or QIO, which is a group of doctors and health professionals. A grievance is not the process clients use when they have an issue with a plan’s refusal to cover a service, supply or prescription. That’s an appeal process.

If you would like to obtain a report of the appeals , grievance , and exceptions filed with the plan, you may contact Member Services and request that information. Call us at the number on your member ID card. You are entitled to obtain an aggregate number of grievances, appeals, and exceptions filed with Aspire Health Plan. Appeal : A request to reconsider and change a decision or determination made about the plan services or benefits or the amount the plan will pay for a service or benefit.

If you are dissatisfied with any aspect of your healthcare plan, Customer Care, your provider or treatment facility, you can submit a grievance at any time. This includes the right to get timely services from our network specialists when you need that care. This appeal can be requested by you, an authorized person, provider or practitioner.

The enrolle e may submit the grievance verbally or in writing. The Beacon HCS Virtual Appeals Manager is a highly configurable and automated solution, designed by health plan compliance and operational experts, provides unparalleled control and transparency of cases from intake to review ensuring complete compliance. After we receive the request, Humana will make a decision and send written notice within thirty (30) calendar days. A grievance is any complaint, or dispute, expressing dissatisfaction with the manner in which our organization or delegated entity provides health care services, regardless of whether you request remedial action be taken.

There may be a time when we deny a claim, a service authorization or a request for services. Or, you may be dissatisfied with the quality of care or services provided.