Learn about your Part C medical care plan’s rights, including:
- Grievances
- Coverage decisions
- Exceptions
- Appeal processes
For more detailed information, refer to Chapter 9 of the Evidence of Coverage.
Your Part C Medical Care Plan Rights
You have certain rights concerning your medical care. Specifically, you have the right to:
- Request a coverage decision
- Make an appeal to deal with problems related to your benefits and coverage for medical services
Asking for coverage decisions
A coverage decision is a determination we make about your benefits and coverage, or about the amount we'll pay for your medical services. We make a coverage decision for you whenever you go to a doctor or other provider for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we'll cover a medical service before you receive it, you can ask us to make a coverage decision for you.
In some cases, we might decide a service or drug isn't covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
Contact Information for Coverage Decisions About Your Medical Care and Services
Time Frames for Standard and Expedited Reviews for Coverage Decisions
Standard Deadlines
When we give you our decision, we'll use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard decision means we will give you an answer within 14 days after we receive your request.
- In some cases, we can take up to 14 more days if you ask for more time, or if we need more information (such as medical records) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.
- If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.
Fast Decision
A fast decision means we'll answer within 72 hours.
- In some cases, we can take up to 14 more days if we find that some information is missing that may benefit you, or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing.
- If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. We will call you as soon as we make the decision.
To get a fast decision, you must meet two requirements:
- You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)
- You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If your doctor tells us that your health requires a "fast decision," we'll automatically agree to give you a fast decision.
- If you ask for a fast decision on your own, without your doctor's support, our plan will decide whether your health requires that we give you a fast decision.
- If we decide that your medical condition doesn't meet the requirements for a fast decision, we will send you a letter that says so (and we'll use the standard deadlines instead. This letter will tell you that if your doctor asks for the fast decision, we'll automatically give a fast decision. The letter will also tell how you can file a "fast complaint" about our decision to give you a standard decision instead of the fast decision you requested.
Step 2: Our plan considers your request for medical care coverage, and we give you our answer. (For Step 1, see the Filing a Grievance tab)
Deadlines for a "fast" coverage decision:
- Generally, for a fast decision, we will give you our answer within 72 hours.
- If we don't give you our answer within 72 hours (or if there is an extended time period, by the end of that period), you have the right to appeal.
- If our answer is yes to part or all of what you requested: We must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our decision, we'll provide the coverage by the end of that extended period.
- If our answer is no to part or all of what you requested, we'll send you a written explanation.
Deadlines for a "standard" coverage decision:
- Generally, for a standard decision, we'll give you our answer within 14 days of receiving your request.
- We can take up to 14 more days ("an extended time period") under certain circumstances.
- If we don't give you our answer within 14 days (or if there is an extended time period, by the end of that period), you have the right to appeal.
- If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our decision, we'll provide the coverage by the end of that extended period.
- If our answer is no to part or all of what you requested, we will send you a written explanation.
Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal.
Additional information on these processes is also included in your Evidence of Coverage.
- If our plan says no, you have the right to ask us to reconsider—and perhaps change—this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want.
- If you decide to make an appeal, it means you are entering Level 1 of the appeals process.
How to make a complaint (file a grievance)
This section explains how to use the process for making complaints. The formal name for "making a complaint" is called "filing a grievance." The complaint process is only used for certain types of problems. This includes issues related to quality of care, waiting times, and the customer service you receive.
What types of items might lead to filing a grievance?
- Unresolved issues with Member Service
- Problems with one of our network providers
- Disagreement with any of our policies or benefit design
- Suspicion of fraud or abuse
- Marketing or sales activities that you feel are inappropriate
Step 1: Contact us promptly—either by phone or in writing. (For Steps 2 and 3, see the 'Standard & Expedited Reviews' tab)
- Usually, calling Member Service is the first step. If there is anything else you need to do, Member Service will let you know.
How we formally respond to grievances
All written grievances must be submitted to us within 60 days of the event or incident that caused your complaint. Your written grievance must contain:
- Your name
- Address and Membership number
- Your signature, or that of an authorized representative, including the date on which it is signed
- A description of the specific event and the date on which it occurred
Quality of Care Complaints
When your complaint is about quality of care, you can make your complaint to the Quality Improvement Organization (QIO).
- The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients.
- To find the name, address, and phone number of the Quality Improvement Organization for your state, look in Chapter 2, Section 4, of your Evidence of Coverage. If you make a complaint to this organization, we'll work with them to resolve your complaint.
- If you wish, you can make your complaint about quality of care to us and also to the Quality Improvement Organization.
You can also get help and information from Medicare
For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare:
You can visit the Medicare website.
How do I appoint a representative to help with a claim and authorize them to act on my behalf?
If you want a friend, relative, your doctor or other provider, or another person to be your representative, you must complete this Medicare Advantage Appointment of Representative Form. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.
Medicare Complaint Form
You can now submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the form below. The Centers for Medicare & Medicaid Services (CMS) values your feedback, and will use it to continue to improve the quality of the Medicare program. If you have any other feedback or concerns, or if this is an urgent matter, please call.
How to make an appeal
If we make a coverage decision and you're not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to see if we were being fair and following all of the rules properly. When we have completed the review, we will give you our decision.
If we say no to all or part of your Level 1 Appeal, your case will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that isn't connected to our plan. If you're not satisfied with the decision at the Level 2 Appeal, you may be able to continue through three more levels of appeal.
Get help asking for a coverage decision or making an appeal
- Call Member Service at the phone number listed below.
- To get free help from an independent organization that isn't connected with our plan, contact your State Health Insurance Assistance Program (SHIP).
- You should consider getting your doctor or other provider involved if possible, especially if you want a "fast" or "expedited" decision. In most situations involving a coverage decision or appeal, your doctor or other provider must explain the medical reasons that support your request. Your doctor can't request every appeal. He/she can request a coverage decision and a Level 1 Appeal with the plan. To request any appeal after Level 1, your doctor must be appointed as your "representative."
Assigning a Representative
You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal.
If you want a friend, relative, your doctor or other provider, or other person to be your representative, you must complete this
Medicare Advantage Appointment of Representative Form. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.
Appeal Review Time Frames
Standard Appeal
If we're using the standard deadlines, we must give you our answer within 30 calendar days if your appeal is about covered services you have not yet received, and within 60 calendar days if your appeal is about covered services you have already received. We'll give you our decision sooner if your health condition requires us to. However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days.
Fast Appeal
When we're using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We'll give you our answer sooner if your health condition requires us to do so. However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we'll tell you in writing.
Contact Information for Coverage Decisions About Your Medical Care and Services