Appeals and Grievances

You have the right to make a complaint if you have concerns or problems related to your coverage or care. "Appeals" and "Grievances" are the two different types of complaints you can make and are discussed below. Appeals and grievances are discussed in more detail in the Evidence of Coverage (Chapter 9 – What to do if you have a problem or complaint (coverage decisions, appeals, complaints):

2010 Evidence of Coverage

• Chronic Condition Special Needs Plan
  • Silver Rx (Regional PPO)
  • Gold Rx (Regional PPO)
  • Gold Rx Advantage (Regional PPO)
• Medicare/Full Medicaid Special Needs Plan
• Medicare Advantage (Regional PPO)
• Arkansas – Medicare Advantage (PPO)

• Chronic Condition Special Needs Plan
  • Silver Rx (Regional PPO)
  • Gold Rx (Regional PPO)
  • Gold Rx Advantage (Regional PPO)
• Medicare Advantage (Regional PPO)

• Chronic Condition Special Needs Plan (English)
  • Silver Rx (Regional PPO)
  • Gold Rx (Regional PPO)
  • Gold Rx Advantage (Regional PPO)
• Chronic Condition Special Needs Plan (Spanish)
  • Silver Rx (Regional PPO)
  • Gold Rx (Regional PPO)
  • Gold Rx Advantage (Regional PPO)
• Medicare/Full Medicaid Special Needs Plan (English)
• Medicare/Full Medicaid Special Needs Plan (Spanish)
• Medicare Advantage (Regional PPO) (English)
• Medicare Advantage (Regional PPO) (Spanish)
• Medicare Advantage (PPO) (English)
• Medicare Advantage (PPO) (Spanish)

• Chronic Condition Special Needs Plan

Medical Care Appeals
If a health care service or claim is denied, or if Care Improvement Plus fails to provide you with a timely organization determination, you have the right to file an appeal in writing. If the denial could jeopardize your health status, you may request an expedited appeal by phone or fax.

The first level of medical appeal is a "reconsideration" and is conducted by the plan's health care professionals and physicians. Care Improvement Plus must gather information and make a determination within a 30-day time period, or within 72 hours for expedited appeals. Time extensions are possible. Claims are decided within 60 days.

If Care Improvement Plus upholds its initial denial, we send the appeal automatically to Medicare's independent review contractor. This second level appeal is also called a reconsideration. If the independent reviewer agrees with the health plan's denial, you have the same rights to all federal levels of appeals and judicial review as do beneficiaries in fee-for-service Medicare.

Appeals Helpful Information:
To obtain a standard appeal, send appeal request in writing to Care Improvement Plus:

By mail:
Care Improvement Plus
Attn: Appeals Department
351 W. Camden Street, Suite 100
Baltimore, MD 21201

By Fax:
1-866-272-2942

To obtain an expedited appeal:
By phone: 1-800-213-0672 (TTY: 1-800-713-1603)
By fax: 1-866-272-2942

To obtain a standard appeal regarding certain medications that have restrictions and are given in the doctor's office, send appeal request in writing to Care Improvement Plus:

By mail:
Care Improvement Plus
Attn: Pharmacy Part C Appeals
351 W. Camden Street, Suite 100
Baltimore, MD 21201

By Fax:
1-866-311-9848

To obtain an expedited appeal:
By phone: 1-866-904-6561 (TTY: 1-800-713-1603)
By fax: 1-866-311-9848

Forms

Authorized Representative
Requests may be made by a family member, friend, or other party if the individual demonstrates legal authority, such as a medical power of attorney. Another way to be delegated this authority is by submitting to the plan a signed Appointment of Representative form.

For prescription drug determinations, physicians may act on behalf of the beneficiary and do not need the authority just described.

Waiver of Liability Statement
Per CMS guidance, a non-contracted provider requesting an appeal must sign a Waiver of Liability Statement before the appeal will be considered by the Health Plan. If the Waiver of Liability Statement is not executed by the non-contracted provider, the Health Plan will close the appeal request and submit the appeal case to CMS Independent Review Entity (Maximus) for dismissal.

Grievances
If you are dissatisfied or have a complaint about any aspect of Care Improvement Plus, you may call or write our Member Services department. Complaints other than those involving organization determinations or coverage determinations are called grievances. (Complaints about denials and other adverse organization determinations or coverage determinations are handled as appeals, and are not grievances.) We will investigate the grievance and respond to you in a timely manner. Complaints about denied requests for an expedited decision or appeal, or disagreements over time extensions, will be handled as expedited grievances – they are reviewed and resolved within 24 hours.

To file a grievance/complaint (standard or expedited) contact Member Services:

To contact Member Services by phone:
1-800-204-1002
(TTY: 1-800-713-1603)
7 days a week 8:00 am - 8:00 pm

To contact us by mail:
Care Improvement Plus
351 W. Camden Street, Suite 100
Baltimore, MD 21201
Attn: Compliance Department