Appeals, Grievances and Exception Requests

Following is complete information that you can use to settle any problem you have with your Quality Health Plans Coverage.

Complaint Procedure Summary

We encourage you to let us know right away if you have questions, concerns, or problems related to your QHP coverage. Florida members should call Member Services at 1-866-747-2700 or TDD at 1-866-455-6010.  New York members should call 1-877-233-7058 or TDD 1-877-681-4984.

Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from your MA-PD Plan or penalized in any way if you make a complaint.

A complaint will be handled as an appeal, grievance, or coverage determination  depending on the subject of the complaint.  An appeal is the type of complaint you make when you want us to reconsider and change a decision we have made about what benefits are covered for you or what we will pay for a prescription drug or treatment.  There are two types of appeals – fast and standard.  The request for a fast appeal must meet criteria that the standard process time frame would jeopardize the members’ health status.  Fast reviews will be completed within 72 hours and standard appeals will be reviewed within 7 calendar days.

A grievance is any complaint other than one that involves a coverage determination involving a treatment or medication. You would file a grievance if you have any type of problem with MA-PD Plan or one of our network providers that does not relate to coverage for a treatment or prescription drug. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.  We will notify you of our decision within 30 days of receipt of the written grievance.  Additional time may be required if we justify the need for additional information and the delay is in your best interest.

You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. The first step in obtaining a coverage determination is to submit a written request.  When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. If you request an exception, your physician must provide a statement to support your request.

You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

To file a grievance or appeal or request a coverage determination you may choose any of the following means:

You can also use the information above to obtain an aggregate number of grievances, appeals and exceptions filed with QHP.  You may find a statement of your rights and responsibilities and this plan's rights and responsibilities in your Evidence of Coverage.

The following forms are available for printing or downloading  to assist you in filing and resolving your complaint.  Each form is accompanied by instructions for completing the form and for filing it.  Click on the name of the form you want to view