Medicare Plan (Ma, Mapd And Part D) Appeals & Grievances Form Page 4
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5Medicare Plan Appeals & Grievances form 4 of 5
Our deadlines for a medical-related appeal
The standard timeframes are:
• For a health care service, supply or item you think you should be able to get: 30 calendar days.
• For a health care service, supply or item you’ve already received: 60 calendar days.
• To change the amount you must pay for a health care service, supply or item: 30 calendar days.
Expedited appeal
An action you can take if you and/or your doctor believe that waiting for a decision under the standard
time frame will place your life, health, or ability to regain function in serious jeopardy.
Our deadline for an expedited appeal
For prescription drug and medical issues: 72 hours. Your appeal won’t be expedited if you’ve already
received the drug or service you are appealing.
Expedited 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.
Our deadline for an expedited grievance
The standard timeframe is 24 hours.
Grievance
A complaint when you are dissatisfied with the quality of service or care that the plan or a provider
gave you. (Examples: rude customer service; a problem with a network facility or provider; confusing
member materials.) If you have a question but not a complaint, please call the Customer Service
number on the back of your member ID card.
Our deadline for a grievance
The standard timeframe is 30 calendar days.
What if it has been more than 60 calendar days since the date of service or incident?
You may need to show you have a good reason for missing it. Examples include: you were in the
hospital during that time; you got the denial notice too late; an accident caused the records to be
destroyed; there was a death or serious illness in your immediate family. Please give your reason
on the first page, under “What you can do if your 60-calendar-day deadline has passed.”
What to include under “Information about your issue”
Please tell us about the issue. Include dates, locations and claim numbers, if you know them.
• What have you already tried to resolve the issue? Include dates if you know them. This will help
us research your issue.
• Tell us what resolution you would like to see. (Examples: get a refund of my out-of-pocket medical
expense; have management to be aware of my complaint; cover my prescription drug.)
• If your date of service or date of incident was more than 60 calendar days ago, please tell us why
you didn’t file within 60 calendar days. You’ll need to have a good cause. (For examples, see
“What if it has been more than 60 calendar days since the date of service or incident?”)
Please include any other information with this form that you would like to provide to help us research
your appeal or grievance. If you use extra pages, be sure to mail or fax them to us with this form.
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Parent category: Medical