Grievance, coverage
determinations, appeals procedures, and exceptions process
We encourage you to let us know right away if
you have questions, concerns, or problems related to your covered services or
the care you receive. Please call Customer Service at 800-336-0123, Monday
through Friday from 8 a.m. to 8
p.m. TTY/TDD users should call 775-982-3240.
Federal law guarantees your right to make
complaints if you have concerns or problems with any part of your medical care
as a Senior Care Plus 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 Senior Care Plus or penalized in any way if you make a
complaint.
You have the right to make a complaint if you have
concerns or problems related to your coverage or care. “Appeals” and
“grievances” are the two different types of complaints you can make.
- An “appeal” is the type of
complaint you make when you want us to reconsider and change a decision we
have made about what services or benefits are covered for you or what we will
pay for a service or benefit. For example, if we refuse to cover or pay for
services you think we should cover, you can file an appeal. If Senior Care
Plus or one of our plan providers refuses to give you a service you think
should be covered, you can file an appeal. If Senior Care Plus or one of our
plan providers reduces or cuts back on services or benefits you have been
receiving, you can file an appeal. If you think we are stopping your coverage
of a service or benefit too soon, you can file an appeal.
- A “grievance” is the type of
complaint you make if you have any other type of problem with Senior Care Plus
or one of our plan providers. For example, you would file a grievance if you
have a problem with things such as the quality of your care, waiting times for
appointments or in the waiting room, the way your doctors or others behave,
being able to reach someone by phone or get the information you need, or the
cleanliness or condition of the doctor’s office.
Please refer to your Evidence of Coverage for more
information regarding Grievance and Appeal Rights or contact Senior Care
Plus.
Revised October 2007
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