Step 1: Contact us promptly by phone or in writing.
Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. Call 1-866-245-5360 (TTY/TDD: 711).
If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here’s how it works:
Send a letter describing your grievance to our Grievance Department at Optimum HealthCare, Inc., P.O. Box 152727, Tampa, FL 33684. Or, you can fax a letter to: 1-813-506-6235.
In your letter, let us know about your complaint, including how to contact you if we have any questions. Please include the date of the incident being grieved about and names of any Plan or Provider representatives you have communicated with already, if possible.
We will notify you of our resolution regarding your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may 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. You can start a grievance that you want resolved faster than the standard grievance. In certain cases, if related to an expedited coverage decision denial or expedited appeal denial, you have the right to ask for a “fast grievance,” meaning we will answer your grievance within 24 hours.
Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.
If you are making a complaint because we denied your request for a “fast response” to a coverage decision or appeal, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.
Step 2: We look into your complaint and give you our answer.
If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
Most complaints are answered within 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint.
If we do not agree with some or all of your complaint or do not take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.
Step 3: You can also tell Medicare about your complaint
You can submit a complaint about the plan directly to Medicare. To submit a complaint to Medicare, go to https://www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.