Grievances and Appeals
What to Do If You Have a Problem or Concern:
- For some types of problems, you need to use the process for organization/coverage decisions and making appeals.
- For other types of problems, you need to use the process for making complaints.
Medicare has approved both of these processes. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. The process you use depends on the type of problem you are having.
The process for organization/coverage decisions deals with problems related to your benefits and coverage for medical services and prescription drugs. This is the process you use for issues such as whether something is covered or not, and the way in which something is covered.
If we make an organization/coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change an organization/coverage decision we have made.
The complaint process is used for certain types of problems only. This includes complaints related to quality of care, waiting times, and the customer service you receive.
Members and providers who have questions about the Grievance and Appeals processes, need the status of an organization/coverage determination or want to receive an aggregate number of grievance, appeals, and exceptions filed with the plan sponsor, please contact Member Services.
Last updated 10/03/2019