Medicare Plan (Ma, Mapd And Part D) Appeals & Grievances Form
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Medicare Plan (MA, MAPD and Part D) Appeals & Grievances Form
You can use this form to file an appeal or grievance. Definitions and helpful information are at the end
of this form. Please type or print in dark ink.
What is your issue or concern about?
Prescription drug
Medical care
Did you already receive the prescription drugs or medical care?
Yes
No
Please tell us what you want to do:
File a standard appeal: ask us to reconsider how we cover or pay for your care or prescription
drugs. Be sure to file no later than 60 calendar days from the date we denied the service.
File an expedited (fast) appeal: an appeal you make when your doctor believes your health
depends on a faster answer. You’ll need to make this appeal before you get the service. We’ll give
you an answer no later than 72 hours. Be sure to file no later than 60 calendar days from the date
we denied the service.
File a grievance: a complaint about quality of care you received, waiting times, customer service or
something similar. Be sure to file no later than 60 calendar days from the date the event happened.
File an expedited (fast) grievance: This is a complaint you can file only after we’ve determined
your appeal doesn’t qualify as an expedited appeal. Or, when we’ve told you we will take an extra
14 days, and you disagree with this action. Be sure to file no later than 60 calendar days from the
date we tell you how much time we’ll take.
What you can do if your 60-calendar-day deadline has passed.
You may need to show you have a good reason for missing it. (Examples: you were too sick, or we
gave you the wrong deadline.) More about deadlines and filing is at the end of this form. Please give
your reason below:
Information about you
First name
Last name
Address
City
State
ZIP code
Home phone number
Cell phone number
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Email address
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Parent category: Medical