Grievances (Part C and D)

As a Medicare beneficiary, you have the right to file a grievance if you are unhappy or dissatisfied with any of the benefits or services you are receiving including prescriptions.

What is a Grievance?

Medicare indicates that a grievance is any complaint, other than one that involves a request for an initial determination or appeal. You would file a “grievance” for any complaint and/or expression of dissatisfaction from you or your authorized representative regarding services, access to providers, timeliness, treatment, prescriptions, or any other issue you wish to address your dissatisfaction.

How to File a Grievance

As an enrollee of Passport Advantage, if your complaint is received by telephone, we will address and resolve your complaint by telephone, especially if your complaint involves a possible misunderstanding or misinformation. If you request a written response, or if your concern is regarding a Quality of Care issue, we will respond in writing to you.

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 you wish to file a grievance with Passport Advantage, you or your designated representative may call Passport Advantage Member Services toll-free at 1-844-859-6152, available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST). TTY/TDD users call 711. You may also submit a grievance in written form.

Please send it to:

Passport Advantage
Attn: Grievance and Appeals
5100 Commerce Crossings Drive
Louisville, KY 40229

Or via Fax: 502-213-8906

Other Options: Ask someone to act on your behalf.  To name someone as your representative, please download and complete the Appointment of Representative Form, then send it to the Plan.  You also have the right to hire a lawyer.

Notice of Right to an Expedited Grievance

 


What is an Appeal?

Appeals for Part C (Medical) Services

Reconsideration is the first level of the appeal process, which involves a Part C plan sponsor reevaluating an adverse organization determination (decision of your Part C medical services), the findings upon which it was based, and any other evidence submitted or obtained.

An Appeal for Medical Services is any of the procedures that deal with the review of adverse organizational determinations that you as the member believe you are entitled to receive. Including delay in providing, arranging for or approving the health care services or any amounts you must pay for a service. You can also file an appeal if you believe Passport Advantage neglected to furnish you with an initial written determination.

Standard appeals must be received in writing within 60 days from the event or incident.

You may send your written appeal to:

Passport Advantage
Attn: Appeals Coordinator
5100 Commerce Crossings Drive
Louisville, KY 40229

Or via Fax: 502-213-8906

Fast” or “Expedited” Appeal

You, your doctor, or your appointed representative may ask us to give a fast appeal (rather than a standard appeal), which is a 72-hour review, by calling Passport Advantage Member Services toll-free at 1-844-859-6152, available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST). TTY/TDD users call 711.

You may also fax it to us at 844-602-4631

Be sure to ask for a “fast,” “expedited,” or “72-hour” review. Remember, that if your prescribing doctor provides a written or oral supporting statement, explaining that you need the fast appeal process, we will automatically treat you as eligible for a fast appeal.

If you need assistance filing an appeal, you or your designated representative may call Passport Advantage Member Services toll-free at 1-844-859-6152, available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST). TTY/TDD users call 711.

Other Options: Ask someone to act on your behalf.  To name someone as your representative, please download and complete the Appointment of Representative Form, then send it to the Plan. You also have the right to hire a lawyer.

 


Appeals for Part D (Pharmacy) Benefits

Redetermination is the first level of the appeal process, which involves a Part D plan sponsor reevaluating an adverse coverage determination (decision of your Part D Pharmacy benefits), the findings upon which it was based, and any other evidence submitted or obtained.

You can generally “appeal” our decision not to cover a drug, vaccine, or other Part D benefit. You may also appeal our decision not to reimburse you for a Part D drug that you paid for or if you think, we should have reimbursed you more than you received or if you are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription.

Finally, if we deny an exception request or you received an adverse coverage determination, you can appeal.

You need to file your standard appeal within 60 calendar days from the date included on the specific notification such as the notice of coverage determination. We can give you more time if you have a good reason for missing the deadline.

To file a standard appeal, you, your designated representative, or your prescribing physician can complete the Request for Redetermination Form and submit by fax, mail, or in person. You may also call Passport Advantage Member Services toll-free at 1-844-859-6152, available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST). TTY/TDD users call 711. You can send the form or another signed request to:

Passport Advantage
Attn: Pharmacy Appeals
950 N Meridian Street, Suite 600
Indianapolis, IN 46204

Or via Fax: 855-869-7043

When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were being fair and following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information. After we get your appeal, we have up to 7 calendar days to give you a decision, but will make it sooner if your health condition requires us to. If we do not give you our decision within 7 calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case.

 “Fast” or “Expedited” Appeal

You, your doctor, or your appointed representative may ask us to give a fast appeal (rather than a standard appeal), which is a 72-hour review, by calling Passport Advantage Member Services toll-free at 1-844-859-6152, available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST). TTY/TDD users call 711.

You may also fax it to us at 855-869-7043 during or outside our regular business hours.

Be sure to ask for a “fast,” “expedited,” or “72-hour” review. Remember, that if your prescribing doctor provides a written or oral supporting statement, explaining that you need the fast appeal process, we will automatically treat you as eligible for a fast appeal.

Other Options: Ask someone to act on your behalf.  To name someone as your representative, please download and complete the Appointment of Representative Form, then send it to the Plan. You also have the right to hire a lawyer.

Note: Please note that after you file an appeal, the plan will review its original decision. If our Plan doesn’t decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan. Please see your (EOC) for more details about the appeals process.

Exceptions to the Formulary

For certain prescription drugs, special rules restrict how and when the plan covers them. If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for you, you will need to use the coverage decision process and ask us to make an exception. An exception is a type of coverage determination that, if approved, allows you to get a drug that is not on the formulary (a formulary exception).

You can ask us to cover a non-formulary drug or to waive coverage restrictions or limits on a drug. For example, with  certain drugs, Passport Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. To view our formulary (or drug list), click here.

You should contact us to ask us for an initial coverage decision for a formulary exception or for a coverage restriction exception. You, your representative, or you doctor (or other prescriber) can do this. A request can be submitted by phone, fax, or mail.

When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

You can read more about formulary exceptions in our Evidence of Coverage.

Requesting an Exception (Members)

Coverage Determination Request Form (Drug Request)
By Mail or Fax

  • Download and print the Coverage Determination Request Form (PDF), or call Member Services at 1-844-859-6152, TTY/TDD 711, and request that the form be mailed to you. Calls to this number are free. Hours of operation are from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST).
  • Complete the entire form and submit either by fax or mail. The fax number and mailing address are listed at the top of the form.
  • Your physician must submit a statement that none of the drugs used to treat your condition on Passport Advantage’s formulary would be as effective, and/or that all of the formulary drugs have caused you adverse effects.
  • To check the status of your exception request, please contact Member Services 1-844-859-6152, TTY/TDD 711; available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST)

Fax Number:
1-855-869-7043

Mail:
Passport Advantage Pharmacy Services
950 N. Meridian Street, Suite 600
Indianapolis, IN 46204

Phone:
1-844-859-6152, TTY/TDD 711; available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST)

For coverage requests, after an initial denial, you will need to use this formRequest for Redetermination Form

 


How To Appoint a Representative

You can ask someone to act on your behalf.

If you want to, you can name another person to act for you as your representative to ask for a coverage decision or make an appeal.

  • There may be someone who is already legally authorized to act as your representative under State law.
  • If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services at 1-844-859-6152, available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST). TTY/TDD users call 711; and ask for the Appointment of Representative‖ (The form is also available on Medicare’s website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf or here on our website Appointment of Representative Form.

The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form and mailed back to:

Passport Advantage
Attn: Member Services
5100 Commerce Crossings Drive
Louisville, Kentucky 40229


For More Information

Members can learn more about coverage determinations, appeals and grievances by reading on this topic in our Evidence of Coverage.

For information on Part D Appeals and Grievances, click here.

You can also contact the Center or Medicare and Medicaid Services (CMS) at 1-800-Medicare for additional details about the grievance and appeals process.  In lieu of calling this number, you can visit the Medicare.gov complaint website at:  www.medicare.gov/MedicareComplaintForm/home.aspx

If you or your provider have questions about the grievance, appeals or exceptions process or who would like to obtain an aggregate number of grievance, appeals or exceptions filed under the plan should contact Member Services at 1-844-859-6152, available from February 15 to September 30, Monday – Friday, 8 a.m. to 8 p.m. (EST) and from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST) TTY/TDD users call 711.  This phone number is also located on the back of your Passport Advantage ID card.

 

Last Modified: June 6, 2018