• Overview
• Grievances (Complaints)
  • Making a Complaint
• Problems/Concerns about Part C Medical Benefits and Coverage
  • Coverage Decisions
  • Appeal a Coverage Decision
• Problems/Concerns about the Part D Prescription Drug Benefit
  • Coverage Decision/Exceptions
  • Appeal a Coverage Decision

GRIEVANCE (Complaints)

A grievance is a type of complaint you make about us or one of our network providers or pharmacies. This type of complaint does not involve coverage or payment disputes. The grievance / complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process:

Quality of your medical care

• Are you unhappy with the quality of the care you have received (including care in the hospital)?

Respecting your privacy

• Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?

Disrespect, poor customer services, or other negative behaviors

• Has someone been rude or disrespectful to you?
• Are you unhappy with how our Member Services has dealt with you?
• Do you feel you are being encouraged to leave our plan?

Waiting times

• Are you having trouble getting an appointment, or waiting too long to get it?
• Have you been kept waiting too long by doctors, other health care professionals or by Member Services or other staff at our plan?
• If you have Medvantage Rx or Medvantage Rx Plus, have you been kept waiting too long by a pharmacist?
• Examples include waiting too long on the phone, in the waiting room, in the exam room, or when getting a prescription.

Cleanliness

• Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor’s office?

Information you get from our plan

• Do you believe we have not given you a notice that we are required to give?
• Do you think written information we have given you is hare to understand?

If you have already asked for a coverage decision or made an appeal, and you think that our plan is not responding quickly enough, you can also make a complaint about our slowness. Here are examples:

• If you have asked us to give you a “fast response” for a coverage determination or appeal, and we have said we will not, you can make a complaint.
• If you believe our plan is not meeting the deadlines for giving you a coverage determination or an answer to an appeal you have made, you can make a complaint.
• When a coverage decision we made is reviewed and our plan is told that we must cover or reimburse you for certain medical services or drugs there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint.
• When our plan does not give you a decision on time, we are required to forward you case to the Independent Review Organization. If we do not do that within the required deadline you can make a complaint