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

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 such issues as the behavior of your pharmacist or excessive wait times at the pharmacy.

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: 502-212-6910

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: If you do not agree with the decision Passport Advantage makes, you can make an appeal. Please see Chapter 9 in your Evidence of Coverage for more details.

What is an Appeal?

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 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 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 send a signed written appeal to:

Passport Advantage
Attn: Grievance and Appeals
5100 Commerce Crossings Drive
Louisville, KY 40229
Or via Fax: 502-212-6910

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 deliver a written request to Passport Advantage at:

Passport Advantage
5100 Commerce Crossings Drive
Louisville, KY 40229

You may also fax it to us at 502-212-6910 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.

 

Notice of Right to an Expedited Grievance

 

Other Options: Ask your doctor or other provider to make the request for you or 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 Chapter 9 in your Evidence of Coverage for more details about the appeals process.

 


How to Ask for a Coverage Decision:

 

Part C Medical Services

Call: 1-844-859-6152 (TTY/TDD users, please call 711) 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), or send the Coverage Determination Form to:

Mail to:
Passport Advantage
5100 Commerce Crossings Drive
Louisville, Kentucky 40229

Part D Prescription Drug

Part D Coverage Determination Request Form

 

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

Fax:
(866) 869-7043

Other Options:

  • Ask your doctor or other provider to make the request for you or 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: If you do not agree with the decision Passport Advantage makes, you can make an appeal. Please see Chapter 9 in your your Evidence of Coverage for more details.

 


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‖ form. (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 Chapter 9 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: October 13, 2017