Appeals & Grievances Policy - 2010

If you have a problem or concern, call us first

Your health and satisfaction are important to us. When you have a problem or concern, we hope you'll try an informal approach first: Please call Member Services. We will work with you to try to find a satisfactory solution to your problem.

You have rights as a member of our plan and as someone who is getting Medicare. We pledge to honor your rights, to take your problems and concerns seriously, and to treat you with respect.

Two formal processes for dealing with problems

Sometimes you might need a formal process for dealing with a problem you are having as a member of our plan.

This page explains two types of formal processes for handling problems:

For some types of problems, you need to use the process for coverage decisions and the process for making appeals.
For other types of problems you need to use the process for making complaints.

Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you.

Asking for coverage decisions

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We make a coverage decision for you whenever you go to a doctor for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay:

Usually, there is no problem. We decide the service or drug is covered and pay our share of the cost.

But in some cases we might decide the service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Learn How to Request a Coverage Determination.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the 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 being fair and following all of the rules properly. When we have completed the review we give you our decision.

If we say no to all or part of your Level 1 Appeal, your case will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal.

To request an appeal, you must contact us by doing one of the following:

Call Member Services,
Fax us your request at 1-215-988-2001
Write to us at:

Passport Advantage Member Appeals
P. O. Box 153098
Tampa, FL 33684

Making a formal complaint ("grievance")

The complaint process is used for certain types of problems, such as problems related to quality of care, waiting times, and the customer service you receive. To make a complaint, call Member Services or write to Passport Advantage Member Services, P.O. Box 153098, Tampa, FL 33684 and tell us that you want to file a grievance. You must submit your complaint within 60 days of the event or incident.

How to get help when you are asking for a coverage decision or appeal

If you want a friend, relative, your doctor or other provider, or other person to be your representative, download the Appointment of Representative Form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.

For More Information

You can learn more about coverage determinations, appeals and grievances by reading Section 9 in our Evidence of Coverage.