Part D Appeals and Grievances

Medicare Advantage Prescription Drug (MA-PD) Plan Appeals and Grievances

As our member, you have the right to file a complaint (either an Appeal or a Grievance) if you have concerns or problems related to your coverage. If you wish to request an aggregate number of Grievances, Appeals and Exceptions filed with Generations Healthcare HMO, contact us at:

• Part D Appeals and Coverage Determinations:
  1-866-316-6049, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-866-684-5351) 7 days a week.
  
• Part D Grievances:
  1-866-547-3060, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) 7 days a week.

What is an Appeal?

An Appeal is a formal way of asking us to reconsider and possibly change a coverage determination we made. You can choose to submit an Appeal if we have already told you that we will not cover or pay for a drug the way you want it covered or paid for.

You can find more information about what your plan covers in your Evidence of Coverage.

How do I file an Appeal with Generations Healthcare?

You must make your Appeal within 60 days of the date on the written notice we sent you notifying you of our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to submit your Appeal. When we review your Appeal, we will give the information you send careful consideration. This includes reviewing whether we followed the rules when we denied your request. We may contact you or your prescriber to get more information.

We must give you our answer within seven days after we receive your request for a standard Appeal. If your health requires an answer sooner than seven days, you may ask for a fast Appeal (also called an expedited Appeal). For a fast Appeal, we must give you our answer within 72 hours after we receive it. You can access an Appeal (Redetermination) Form here.

To file a standard Appeal, you can send us the Appeal request in writing to:

• Appeals and Coverage Determination
  PO Box 391197
  Solon, OH 44139-3911
  Toll Free Fax: 1-866-868-0858

You may also file an Appeal by phone. To file an Appeal, request information or ask for assistance, call us at 1-866-316-6049, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-866-684-5351) 7 days a week.

If we deny all or part of your Appeal request, you or your appointed representative may request a review by an independent review entity (IRE). The IRE is contracted directly with the federal government and is not affiliated with Generations Healthcare in any way. You can access a Reconsideration Form (PDF) here.

Reconsideration Notice

If you do not agree with the Redetermination decision, you should use this Reconsideration Form (PDF) to Appeal your claim. This is called a Reconsideration, and is the second level of the Appeals process. Any dollar amount can be appealed at this level, but your appeal must be submitted within 60 days from the date you received the written Redetermination notice.

To file a Reconsideration Form, send or fax the form in writing to:

• MAXIMUS Federal Services
  Medicare Part D QIC
  860 Cross Keys Office Park
  Fairport, NY 14450
• Fax number: 585-425-5390
• Toll-Free Fax: 866-825-9507
• Member Services: 1-585-425-5300
• Toll-Free Member Services: 1-877-456-5302

You may also file a Reconsideration Form by phone or fax. If you have general questions about the Reconsideration Form, call us at 1-866-316-6049, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-866-684-5351) 7 days a week.

Please refer to Chapter 7 on Appeals in your Evidence of Coverage, for more information on what to do next.

What is a Grievance?

A Grievance is a complaint you file for any other problem or issue with Generations Healthcare or one of our network pharmacies.

When should I file a Grievance?

• If you have a problem with waiting times when filling a prescription at a network pharmacy
• If you believe the behavior at a network pharmacy is inappropriate
• If you are having difficulty reaching someone by phone or getting information you requested
• If you have a problem with the cleanliness or conditions of a network pharmacy
• If you experience a problem with Generations Healthcare Member Services
• If you don’t understand or are confused by written materials provided by Generations Healthcare

How do I file a Grievance with Generations Healthcare?

If you have a Grievance or a question about Grievances, we encourage you to first call us at 1-866-547-3060, 8:00 a.m. to 8:00 p.m. (TTY users call 1-800-958-2692) 7 days a week. We will try to resolve any complaint that you might have over the phone.

If you request a written response to your phone complaint, we will respond to you in writing. If we cannot resolve your complaint over the phone, we will resort to using a formal procedure to review your complaints. We call this the Generations Healthcare Grievance Process.

You may file a Grievance by telephone, fax, or through the mail, no later than 60 days after the event that caused the Grievance. We will respond to all written Grievances no later than 30 days from the date Generations Healthcare received the Grievance.

If your Grievance involves a refusal by Generations Healthcare to grant your request for an expedited Coverage Determination or an Expedited Redetermination, and you have not yet received the medication that is in dispute, you may file an expedited (fast) Grievance. To file an expedited Grievance, please contact us at 1-866-547-3060, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) 7 days a week, or fax your written complaint to 1-866-868-0858. In this case, you will receive a response within 24 hours.

You can file a Grievance by mailing us your written complaint to:

• Generations Healthcare
• c/o Appeals and Grievances
  P.O. Box 742608
  Houston, TX 77274
  Fax: 1-800-817-3516

Please do not file an expedited Grievance by mail, as we cannot guarantee a response within 24 hours.

In certain circumstances, Generations Healthcare may extend the 30-day response time by 14 days. We may also extend the time frame if you request us to do so. Generations Healthcare may further extend the time frame if we are in need of additional information. If so, we will only extend the time frame if the delay is in your best interest. You will receive a letter notifying you of the extension.

Please refer to Chapter 7 on Grievances in your Evidence of Coverage, for more information on what to do next.

Our decision is final and cannot be Appealed. However, you always have the option to make a complaint with Medicare

If you would like to submit your complaint to Medicare, click on the Medicare Complaint Form to access the form. Please note you do not have to use the Medicare Compliant Form to make a complaint to Medicare. Your options include:

• The Office of the Medicare Ombudsman (OMO) helps you with complaints, Grievances and information requests.
• The Medicare.gov website for more information. Per Medicare regulations, all Grievance decisions are final.
• Calling Medicare at 1-800-MEDICARE (1-800-633-4227); TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week.

(By clicking on these links you will be leaving our website).

Appointing a Representative

As our member, you can appoint a caregiver or someone to act as an official representative on your behalf. We must have your written authorization signed by both you and the person you wish to designate as your Appointed Representative.

A representative who is appointed by the court or who is otherwise authorized under state law to act on your behalf in this regard may also file a request on your behalf, after sending us the supporting legal documentation. You will not need to complete an Appointment of Representative Form if you send supporting documentation with your request showing that another person is authorized to act on your behalf under state law.

Download an Appointment of Representative form (PDF). Once the form is filled out in its entirety, fax it to us at 1-866-684-5378.

Exceptions and Prior Authorizations

Exceptions: You or your doctor may ask us to make an exception to our Part D coverage rules in a number of situations. An exception is a type of coverage determination. As our member, you have the right to request several types of exceptions.

Prior Authorizations: Generations Healthcare requires you to get prior authorization for certain medicines. This means that you will need to get approval from your plan before you fill your prescription. If you do not get approval, Generations Healthcare may not cover the medicine.
Learn more about both Exceptions and Prior Authorizations.

Read about the Generations Healthcare HMO Transition Policy.