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National Home Members Member Information Appeals & Grievances
 

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.

Medicare provides a way for you to submit feedback about your Medicare health plan. Please click on this link to go directly to the Medicare Complaint Form. You can also go to Medicare.gov for more information.

Click here for information relating to your plan's grievance, coverage, determination and appeals process. Appeals and grievances are discussed in more detail in the Evidence of Coverage found below (Chapter 9 – What to do if you have a problem or complaint (coverage decisions, appeals, complaints):

2015 Evidence of Coverage

Arkansas In the Medicare Part D section of the web site you can read more about prescription drug appeals.

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.

Part C Appeals
To obtain a standard medical care appeal, send appeal request in writing to Care Improvement Plus:

By mail:
Care Improvement Plus
Attn: Appeals Department
6514 Meadowridge Rd, 1st Floor
Elkridge, MD 21075

By Phone: 1-800-213-0672 (TTY:711)
By Fax: 1-866-272-2942

To obtain an expedited appeal:

By Phone: 1-800-213-0672 (TTY:711)
By Fax: 1-866-272-2942

Grievances
To file a grievance/complaint (standard or expedited) you can contact Member Services at 1-800-204-1002 (TTY: 711) or write to us at:

By mail:
Care Improvement Plus
Attn: Grievance Department
6514 Meadowridge Rd, 1st Floor
Elkridge, MD 21075

Forms (2015)

Appointment of Representative form - 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. A physician may request a coverage determination on a member’s behalf without 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: 711)
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



This page was last updated on: 12/19/2014 10:33:40 AM

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Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Medicare evaluates plans based on a 5-Star rating system. Star ratings are calculated each year and may change from one year to the next.

Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity and restrictions may apply. It may cost more to get care from out–of–network providers, except in an emergency. If there isn’t a network provider available for you to see, you can go to an out–of–network provider but still pay the in–network amounts. The health providers in our network can change at any time.

To be eligible for a Care Improvement Plus Regional PPO plan you must be a Medicare beneficiary living in Arkansas, Georgia, Missouri, South Carolina, or Texas and have both Medicare Part A and Part B to enroll.

To be eligible for a Care Improvement Plus Local PPO plan you must be a Medicare beneficiary living in select counties of: Arkansas, Georgia, Illinois, Indiana, Iowa, Missouri, Nebraska, New Mexico, North Carolina, South Carolina, Texas or Wisconsin and have both Medicare Part A and Part B to enroll.

To be eligible for a Care Improvement Plus Chronic Conditions Special Needs Plan, you must have diabetes and/or heart failure and/or, cardiovascular disorder. This plan is available to anyone having a qualifying chronic care condition. Members may enroll in the plan only during specific times of the year. Contact Care Improvement Plus for more information. If you have diabetes, heart failure, cardiovascular disorder or Medicaid/Low Income Subsidy, you may qualify to enroll in a Care Improvement Plus Special Needs Plan ANYTIME of the year by exercising a “Special Election Period.

To be eligible for a Care Improvement Plus Dual Advantage Plan, you must be enrolled in state Medicaid and be a dual eligible beneficiary whom the State holds harmless for Part A and Part B cost sharing. This plan is available to anyone who has both medical assistance from the state and from Medicare. If you are a full benefit dual beneficiary and your Part B premium is paid for by the State, you will not be responsible for paying your Part B premium. Premiums, copays, co-insurance and deductibles may vary based on the level of extra help you receive. Please contact the plan for further details.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call:

  • 1–800–MEDICARE (1–800–633–4227). TTY users should call 1–877–486–2048, 24 hours a day/7 days a week;
  • The Social Security Office at 1–800–772–1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1–800–325–0778; or
  • Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1– 800–772–1213.TTY users should call 1–800–325–0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a part of this premium, we will bill you for the amount that Medicare doesn’t cover.


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