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As a member of our plan you have a right to ask us for a coverage decision, to reconsider decisions we have made and to make complaints. You
also have the right to know the number of and what happened to appeals, grievances and exceptions filed by our Members, which you may find
out by contacting Member Services and asking us to send you this information.
Below, we explain what to do if you have a problem or complaint. You can also find more information in Chapter 9, of the Evidence
of Coverage; What to do if you have a problem or complaint (coverage decisions, appeals, complaints). This chapter tells you step-by-step
what to do if you are having problems or concerns as a member of our plan. It explains how to ask for coverage decisions and make appeals
if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. This includes asking us to make
exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and
certain types of medical services if you think your coverage is ending too soon. It also explains how to make complaints about quality of
care, waiting times, customer service, and other concerns.
Appointing a Representative
If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision, make an appeal or file a
grievance. There may be someone who is already legally authorized to act as your representative under State law. If you want a friend,
relative, your doctor or other provider, or other person to be your representative, call Member Services and ask for the “Appointment of
Representative” form. The form is also available on Medicare’s website at:
www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf
The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your
behalf. You must give us a copy of the signed form.
Coverage Decisions for Medical Care
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services
Here is how to contact us when you are asking for a coverage decision about your medical care:
- CALL 1-888-657-4170, Calls to this number are free. Our hours are Monday through Sunday from 8:00 am-8:00 pm
Eastern. From February 15 to September 30, we may use alternative technologies to answer your call on weekends
and Federal holidays. Member Services also has free language interpreter services available for non-English speakers.
TTY 711
- FAX 1-855-895-4748
- WRITE Ultimate Health Plans, Inc., P.O. Box 3146, Scranton, PA 18505
Appeals for Medical Care
An appeal is a formal way of asking us to review and change a coverage decision we have made.
Here’s how to contact us when you are making an appeal about your medical care:
- CALL 1-888-657-4170, Calls to this number are free. Our hours are Monday through Sunday from 8:00 am-8:00 pm
Eastern. From February 15 to September 30, we may use alternative technologies to answer your call on weekends
and Federal holidays. Member Services also has free language interpreter services available for non-English speakers.
TTY 711
- FAX 1-855-895-4748
- WRITE Ultimate Health Plans, Inc., Appeals & Grievances Department, P.O. Box 6560, Spring Hill, FL 34611
Complaints About Your Medical Care
You can make a complaint about us or one of our network providers, including a complaint about the quality of your care. This
type of complaint does not involve coverage or payment disputes. (If your problem is about the plan’s coverage or payment, you
should look at the section above about making an appeal.)
You may also click on the following link to reach CMS’s Model Prescription Drug Determination Request Form.
Here’s how to contact us when you are making a complaint about your medical care:
- CALL 1-888-657-4170, Calls to this number are free. Our hours are Monday through Sunday from 8:00 am-8:00 pm
Eastern. From February 15 to September 30, we may use alternative technologies to answer your call on weekends
and Federal holidays. Member Services also has free language interpreter services available for non-English speakers.
TTY 711
- FAX 1-855-895-4748
- WRITE Ultimate Health Plans, Inc., Appeals & Grievances Department, P.O. Box 6560, Spring Hill, FL 34611
- MEDICARE WEBSITE: You can submit a complaint about our plan directly to Medicare. To submit an online complaint to Medicare
go to www.medicare.gov/MedicareComplaintForm/home.aspx
Coverage Decisions for Part D Prescription Drugs
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your Part D prescription drugs.
Here’s how to contact us when you are asking for a coverage decision about your Part D prescription drugs:
Appeals for Part D Prescription Drugs
To file an appeal (request for redetermination) for a Medicare
prescription drug denial please have your provider complete the form below:
And/Or
Contact us in making an appeal about your Part D prescription drugs:
- CALL 1-800-311-7517, Calls to this number are free. Our hours of Operation: 24 hours a day, 7 days a week. TTY 711
- FAX 1-877-239-4565
- WRITE OptumRx, Prior Authorization Department, c/o Appeals Coordinator, P.O. Box 25184, Santa Ana, CA 92799
Complaints About Your Part D Prescription Drugs
You can make a complaint about us or one of our network pharmacies, including a complaint about the quality of your care. This
type of complaint does not involve coverage or payment disputes. (If your problem is about the plan’s coverage or payment, you
should look at the section above about making an appeal.)
Here’s how to contact us when you have complaints about Part D prescription drugs:
- CALL 1-800-311-7517, Calls to this number are free. Our hours of Operation: 24 hours a day, 7 days a week. TTY 711
- FAX 1-800-313-2798
- WRITE Ultimate Health Plans, Inc., Appeals & Grievances Department, P.O. Box 6560, Spring Hill, FL 34611
- MEDICARE WEBSITE: You can also submit a complaint about our plan directly to Medicare. To submit an online
complaint to Medicare go to
www.medicare.gov/MedicareComplaintForm/home.aspx
The Medicare Beneficiary Ombudsman
The Medicare Beneficiary Ombudsman is a person who reviews and helps you with your Medicare complaints. They make sure information
about your Medicare coverage, your Medicare rights and protections, and how you can get issues resolved is available to all people
with Medicare. To contact the Medicare Beneficiary Ombudsman, call 1-800-MEDICARE, or you can get more information by clicking on
the link:
www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html
Non-Par Provider Appeals
A non-contracted provider, on his or her own behalf, is permitted to file a standard appeal (in writing) for a denied claim only
if the provider completes a Waiver of Liability statement, which states that the non-contracted provider will not bill the enrollee
regardless of the outcome of the appeal. The purpose of this statement is to ensure that the member will not be held financially
liable if the provider loses the appeal.
You must submit your request to file an appeal and your Waiver of Liability Statement within 60 days from the remittance notification.
Please send the signed form and supporting documentation to the following address or fax number:
Ultimate Health Plans, Inc.
Appeals and Grievances Department
P.O. Box 6560
Spring Hill, Florida 34611
Fax #: 1-855-895-4748