Appeals and Grievances

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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.

• Evidence of Coverage Can be found in the Plan Documents section of this website.

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

Appeals for Medical Care

An appeal is a formal way of asking us to review and change a coverage decision we have made.

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.

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.

Appeals for Part D Prescription Drugs

An appeal is a formal way of asking us to review and change a coverage decision we have made.

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.)

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

• Waiver of Liability Statement