• Overview
• Grievances
  • How to File a Grievance
• Complaints about Part C Medical Services and Benefits
  • Organization Determination
  • Appeal a Determination
• Complaints about Part D Prescription Drug Benefit
  • Coverage Determination
  • Ask for an Exception
  • Appeal a Determination

Grievances

A grievance is any complaint other than one that involves a request for an initial determination, or an appeal. Grievances do not involve problems related to approving or paying for Part D drugs, Part C medical care or services, problems about having to leave the hospital too soon, and problems about having Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending too soon.

What types of problems might lead to your filing a grievance:

• Problems with the quality of medical care or services you receive, including quality of care during a hospital stay.
• If you feel that you are being encouraged to leave (disenroll from) the Plan.
• Problems with the service you receive from Member Services.
• Problems with how long you have to wait on the phone, in the waiting room or in the exam room.
• Problems getting appointments when you need them or waiting too long for them.
• Waiting too long for prescriptions to be filled.
• Rude behavior by doctors, nurses, receptionists network pharmacists or other staff.
• Cleanliness or condition of doctor's offices, clinics, network pharmacies or hospitals.
• If you disagree with our decision not to give you a "fast" decision or a "fast" appeal.
• You believe our notices & other written materials are hard to understand.
• We don't give you a decision within the required timeframe (on time).
• We don't forward your case to the Independent Review Entity (IRE) if we do not give you a decision on time.
• We don't give you required notices.

In certain cases you have the right to ask for a "fast grievance" meaning we will answer your grievance within 24 hours. We will try to resolve your complaint over the phone. If we cannot resolve your complaint over the phone we have a formal Grievance procedure to review your complaint. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We can extend the timeframe by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.