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.

Filing a Grievance

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.

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.

If you want someone other than yourself to be your representative, see the section How To Appoint a Representative at the bottom of this page.

Right to an Expedited (fast) Grievance

As a member of our plan, you have the right to file an expedited grievance (fast complaint) for specific circumstances. An expedited grievance (fast complaint) is resolved within 24 hours. A standard grievance is generally resolved within 30 days from the date we receive your request unless your health or condition requires a quicker response. If additional information or an extension is required, we may extend that timeframe by up to 14 days.

If you are making a complaint because we denied your request for a “fast coverage decision” or “fast appeal”, we will automatically give you a “fast complaint.” If you have a fast complaint, we will give you an answer within 24 hours.

If you wish to file a grievance with Passport Advantage, you or your designated representative may contact us in one of the following ways:

By Phone:
1-844-859-6152
We are available from April 1 to September 30, Monday – Friday, 8 am to 9 pm EST (8pm CST) and from October 1 to March 31, 7 days a week, 8 am to 9 pm EST (8pm CST). TTY/TDD users call 711.

By Mail:
Passport Advantage
Attn: Grievance and Appeals
PO BOX 11245
Portland, ME 04104

By Fax:
1-888-727-6231

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 April 1 to September 30,
    Monday – Friday, 8 am to 9 pm EST (8pm CST) and from October 1 to March 31, 7 days a week, 8
    am to 9 pm EST (8pm CST). 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:

By Mail:
Passport Advantage
Attn: Grievance and Appeals
PO BOX 11245
Portland, ME 04104

By Fax:
1-888-727-6231

For More Information

Members can learn more about grievances in our Evidence of Coverage.

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 Passport Advantage Member Services at 1-844-859-6152, available from April 1 to September 30, Monday – Friday, 8 am to 9 pm EST (8pm CST) and from October 1 to March 31, 7 days a week, 8 am to 9 pm EST (8pm CST). TTY/TDD users call 711. This phone number is also located on the back of your Passport Advantage ID card.

 

Last Modified: May 18, 2020