Organization Determination and Appeals (Part C)

If you are having problems related to your benefits and coverage for medical services (Part C), you should follow one of the processes below.

For information on Part D Coverage Decisions, Appeals, and Formulary Exceptions click here.

Asking for an Organization Determination

An organization determination is a decision we make about your benefits and coverage, or about the amount we will pay for your medical services.

You, your doctor, or your authorized representative can contact us and ask for an organization determination if your doctor is unsure whether we will cover a particular medical service, or if your doctor refuses to provide the medical care or services you think you need.

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.

You can ask for a decision about medical care or services (Part C) in one of the following ways:

Call:
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: Utilization Management
5100 Commerce Crossings Drive
Louisville, KY 40229

By Fax:
Inpatient: 1-888-216-0579
Outpatient: 1-888-367-7480

Asking for an Appeal

If we say we will not cover your medical care or services, you have the right to appeal our decision.  An appeal is a formal way of asking us to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original decision.

To start your appeal, you, your doctor, or your authorized representative can contact Passport Advantage.  If you are asking for a standard appeal, you must make your appeal by submitting a written request.  We will give you a written decision within 30 days after receiving the request for medical services or items.

If your health requires an expedited decision, you may ask for a fast appeal.  If you need a fast appeal, you may make your appeal in writing or you may call us.  If your doctor provides a written or oral statement explaining you need the fast appeal process, we will automatically process your appeal as expeditiously as your health requires, but no later than 72 hours after receiving the request.

You must make your appeal request within 60 calendar says from the date on the written notice we sent you about your request for an organization determination.

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.

By Phone (for fast appeal):
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 (for standard appeal):
Passport Advantage
Attn: Grievance and Appeals
PO BOX 11245
Portland, ME 04104

By Fax (for standard or fast appeal):
1-888-727-6231

If your appeal is for payment of a medical service or item you’ve already received, we’ll give you a written decision within 60 days after receiving the request.  You must file your appeal for payment in writing, either by mail or by fax.

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 a.m. to 8 p.m. (EST/CST) and from October 1 to March 31, 7 days a week, 8 a.m. to 8 p.m. (EST/CST). 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:

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 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 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