What to Do if You Have Complaints
(Appeals or Grievance)
Optimum HealthCare encourages you to let the company know right away if you have questions, concerns, or problems related to your prescription drug coverage. Please call our Customer Service Department at 866-245-5360 or TTY at 800-955-8771.
What is a Grievance?
A grievance is any complaint other than one that involves a coverage determination. You file a grievance if you have any type of problem with the Optimum Healthcare Gold Plan or the Optimum Healthcare Platinum Plan, or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem with waiting times when you fill a prescription, the way your network pharmacist or others behave, your ability to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.
What Is an Appointed Representative?
You may appoint any individual (such as a relative, friend, advocate, attorney,
physician, or an employee of a pharmacy, charity, state pharmaceutical assistance
program, or other secondary payor) to act as your representative. A surrogate could also include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney or a health care proxy, or a person designated under a health care consent statute.
The Representative Statement must include your name and Medicare number. You may use the Appointment of Representative form. You may also use an equivalent written notice. A notice is an "equivalent written notice" if it:
- Includes your name, address, and telephone number and Medicare number.
- Includes the name, address, and telephone number of the individual being
appointed.
- Contains a statement that you are authorizing the representative to act on
your for the claim(s) at issue, and a statement authorizing disclosureof individually identifying information to the representative.
- Is signed and dated by the enrollee making the appointment* and
- Is signed and dated by the individual being appointed as representative, and is
accompanied by a statement that the individual accepts the appointment.
* if the member is incapacitated or legally incompetent, there must be other legal papers that support the appointment
What is a Coverage Determination?
Whenever you have a question or concern about your Part D prescription drug benefit, the first step is called “requesting a coverage determination.” When Optimum Healthcare makes a coverage determination, we are making a decision about whether or not to provide or pay for a Part D drug and what your share of the cost is Coverage determinations include exceptions requests. You have the right to ask the company for an exception if you believe that you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request. You must contact Optimum Healthcare if you would like to request a coverage determination (including an exception). You cannot request an appeal if the company has not issued a coverage determination.
To request a Coverage Determination click the appropriate link below:
Coverage Determination/Tier Exception Request- Member
Coverage Determination Request- Provider
What is an appeal?
An appeal is any of the procedures that deal with the review of an unfavorable
coverage determination for Medical or Prescription drugs. You would file an appeal if you want Optimum Healthcare to reconsider a decision made about your Medical or Part D prescription drug coverage.
|
