File a Complaint

What if I have a grievance or appeal?

A grievance is a complaint that shows you are not satisfied with the plan or pharmacy's service. We do have a process to receive grievances, exceptions, and appeals. For information about that process, please view the 2012 Grievances, Exceptions and Appeals Process. For instructions on how to file a grievance, exception or appeal, please view the 2012 Grievances, Exceptions and Appeals Process Instructions.

What is a grievance?

A grievance is any complaint, other than one that involves a request for an initial determination or an appeal. Grievances do not involve problems related to approving or paying for Part D drugs, Part C medical care or services, problems about having to leave the hospital too soon, and problems about having Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending too soon. If we will not pay for or give you the Part C medical care or services or Part D drugs you want, you believe that you are being released from the hospital or SNF too soon, or your HHA or CORF services are ending too soon, you must follow the rules outlined in the 2012 Grievances, Exceptions and Appeals Process within the 2012 Evidence of Coverage.

What types of problems might lead to your filing a grievance?

  • Problems with the service you receive from Member Services
  • If you feel that you are being encouraged to leave (disenroll from) the Plan
  • If you disagree with our decision not to give you a "fast" decision or a "fast" appeal
  • We don't give you a decision within the required timeframe
  • We don't give you required notices
  • You believe our notices and other written materials are hard to understand
  • Waiting too long for prescriptions to be filled
  • Rude behavior by network pharmacists or other staff
  • We don't forward your case to the Independent Review Entity if we do not give you a decision on time
  • Problems with the quality of the medical care or services you receive, including quality of care during a hospital stay
  • Problems with how long you have to wait on the phone, in the waiting room, or in the exam room
  • Problems getting appointments when you need them, or waiting too long for them
  • Rude behavior by doctors, nurses, receptionists, or other staff
  • Cleanliness or condition of doctor's offices, clinics, or hospitals

If you have one of these types of problems and want to make a complaint, it is called "filing a grievance."

Who may file a grievance?

You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call Member Services.

Filing a grievance with our Plan

If you have a complaint, you or your representative may call the phone number for Part C Grievances (for complaints about Part C medical care or services) or Part D Grievances (for complaints about Part D drugs) in Section 8. We will try to resolve your complaint over the phone. If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this our grievance process. You or your representative may file your grievance in writing or verbally. Your grievance must be filed within 60 days of the occurrence. Direct your written grievances to the following addresses:

CareSource Advantage (HMO SNP)
Attn: Grievance Department
P.O. Box 1947
Dayton, OH 45401 -1947
Part D Grievances
CVS Caremark
Attn: Grievance Department
MC121
P.O. Box 53991
Phoenix, AZ 85072-3991

Members will be notified of their right to file a fast grievance: if you disagree with a decision to not conduct expedited organization/coverage determinations or reconsiderations/re-determinations or to take extensions on initial decisions or appeals. You may mail your request to the address listed above, or contact Member Services at 1-800-708-8729  (TTY: 1-800-750-0750 or 711). Your request for a fast grievance will be responded to within 24 hours.

Please provide the following information: your name, address, telephone number and member identification number, you or your authorized representative's signature. Include the date and a summary of the grievance. Authorized representatives are required to complete form CMS-1696 Appointment of Representative form or provide other conforming instrument. To get the form, contact Member Services at 1-800-708-8729. Member Services is open Monday through Friday, 8 a.m. to 8 p.m. (TTY: 1-800-750-0750 or 711).

The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we deny your grievance, in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.

Fast grievances

In certain cases, you have the right to ask for a "fast grievance," meaning we will answer your grievance within 24 hours.

For quality of care problems, you may also complain to the QIO

You may complain about the quality of care received under CareSource Advantage, including care during a hospital stay. You may complain to us using the grievance process, to the Quality Improvement Organization (QIO), or both. If you file with the QIO, we must help the QIO resolve the complaint.

Definition of Quality Improvement Organization (QIO) - Groups of practicing doctors and other health care experts that are paid by the federal government to check and improve the care given to Medicare patients. They must review your complaints about the quality of care given by Medicare providers.

 

 

 

 

H6178_OHMSNP607
CMS Approved 12/20/2011