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Part D Appeals & Grievances (Redetermination)

An appeal or "redetermination" is any of the procedures that deal with the review of an unfavorable coverage determination. You should file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

You can also Contact Us to get the total number of grievances, appeals, and exceptions filed with us; to question processes; or to ask about the status of a previously submitted grievance, appeal or exception. 

For an Expedited Appeal: We suggest contacting us by telephone or submitting your request by fax. Be sure to ask for a "fast or expedited review." This means you are asking us to give you an answer using the expedited deadlines rather than the standard deadlines. You can request an expedited (fast) appeal for cases that involve prescription drug coverage determinations if you or your doctor believes that your health could be seriously harmed by waiting up to 7 days for a decision. If your request to expedite is granted, we must make a decision no later than 72 hours after receiving your appeal. 

For a Standard Appeal: Make your standard appeal in writing by submitting a request.  Standard appeals must be in writing. Please send your appeal to us at the address or fax below. You can request a standard appeal for a case that involves prescription drug coverage or payment determinations. We must give you a decision no later than 7 days after receiving your appeal with up to 30 days to process payment for claim appeals.

You may write to us or use the below forms to Request Appeal Redetermination of Medicare Prescription Drug Denial:

University of Maryland Health Advantage
Attention:  Appeals & Grievance Department
1966 Greenspring Drive, Suite 100
Timonium, MD 21093

For your convenience, you can also use our online form to electronically request your appeal.  Please see the Pharmacy Forms section of this website.

For more information about your appeal rights, call Member Services at the number located on the back of your ID card, refer to the Evidence of Coverage, or visit the Contact Us page of this website. 

GRIEVANCES

The grievance process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the grievance process.

Grievance

Example

Quality of your medical care

  • Are you unhappy with the quality of the care you have received (including care in the hospital)?

Respecting your privacy

  • Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?

Disrespect, poor customer service, or other negative behaviors

  • Has someone been rude or disrespectful to you?
  • Are you unhappy with how our Member Services has treated you?
  • Do you feel you are being encouraged to leave the plan?

Waiting times

  • Are you having trouble getting an appointment, or waiting too long to get it?
  • Have you been kept waiting too long by doctors, pharmacists, or other health professionals? Or by our Member Services or other staff at the plan?
    • Examples include waiting too long on the phone, in the waiting room, when getting a prescription, or in the exam room.

Cleanliness

  • Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor’s office?

Information you get from us

  • Do you believe we have not given you a notice that we are required to give?
  • Do you think written information we have given you is hard to understand?

Timeliness
(These types of grievances are all related to the timeliness of our actions related to coverage decisions and appeals)

If you are asking for a decision or making an appeal, you use that process, not the grievance process. However, if you have already asked us for a coverage decision or made an appeal, and you think that we are not responding quickly enough, you can also make a grievance about our slowness. Here are examples:

  • If you have asked us to give you a “fast coverage decision” or a “fast appeal, and we have said we will not, you can make a grievance.
  • If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a grievance.
  • When a coverage decision we made is reviewed and we are told that we must cover or reimburse you for certain medical services or drugs, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a grievance.
  • When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a grievance.

 

To file a grievance you can do the following: 

  • Usually, calling Member Services is the first step. You can call Member Services at the number located on the back of your ID card, refer to the Evidence of Coverage, or visit the Contact Us page of this website.
  • If you do not wish to call (or you called and were not satisfied), you can put your grievance in writing and send it to us. If you put your grievance in writing, we will respond to your grievance in writing.  Submit your written grievance to us at:

    University of Maryland Health Advantage
    Attention:  Appeals & Grievance Department
    1966 Greenspring Drive, Suite 100
    Timonium, MD 21093

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 grievance. 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 we do not accept your grievance in the whole or in part, our written decision will explain why it was not accepted, and will tell you about any dispute resolution options you may have.

Whether you call or write, you should contact Member Services right away. The grievance must be made within 60 calendar days after you had the problem you want to complain about.

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

How to appoint someone to act on your behalf

You or your physician may request an initial determination or file a grievance or appeal. You may name a relative, friend, advocate, doctor or anyone else as your “appointed representative” to act for you. You may already have a representative authorized under State law to act for you; however, if you want someone to act for you, you and your representative must sign and date a statement giving the person legal permission to be your appointed representative. The form is available below. Please contact your plan for more information.

Appointment of Representative Form