Appeals & Grievances Policy - 2011What to do if you have a problem or complaint
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STEP 1: Which of these situations are you in? |
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| Situation: | I have a problem or concern that is NOT about Passport Advantage benefits or coverage. |
| What to do: | You need to file a grievance. |
| Situation: | I want to find out if Passport Advantage will cover the medical care or medicine I want. |
| What to do: | You need to ask for a coverage decision. Note: There are two kinds of coverage decisions. (1) A coverage determination is a decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. (2) An organization determination is a decision about whether medical services are covered or how much you have to pay for covered services. |
| Situation: | I want Passport Advantage to pay me back for medical care or medicines that I have already received and paid for. |
| What to do: | You need to ask for a coverage decision. |
| Situation: | Passport Advantage has already told me that they will not cover or pay for a medical service or medicine in the way I want it to be covered or paid for. |
| What to do: | You need to make an appeal. |
STEP 2: Contact Us |
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How to file a grievance: |
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| CALL | 1-800-578-0603, then press 1 (TTY users call 1-800-648-6056) |
| WRITE | Passport Advantage Member Services, P.O. Box 153098, Tampa, FL 33684 |
| FAX | 1-813-506-6252 |
| OTHER OPTIONS | Ask someone to act on your behalf. To name someone as your representative, please download and complete the Appointment of Representative Form, then send it to the Plan. You also have the right to hire a lawyer. |
| Note: If you do not agree with the decision Passport Advantage makes, you can make an appeal. Please see your Evidence of Coverage for more details. |
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How to ask for a coverage decision: |
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| CALL | 1-800-578-0603, then press 1 (TTY users call 1-800-648-6056) |
WRITE |
Download the Coverage Determination Form For problems with Part D medicines, write to: Passport Advantage, Attn: Prior Authorization, 200 Stevens Drive, Philadelphia, PA 19113 For problems with Part C medical services, write to: Passport Advantage Member Services, P.O. Box 153098, Tampa, FL 33684 |
| FAX | For problems with Part D medicines, fax to: 1-866-369-6038 (standard) or 1-866-533-5491 (urgent). Note: there is no fax for Part C. |
| OTHER OPTIONS | Ask your doctor or other provider to make the request for you. Ask someone to act on your behalf. To name someone as your representative, please download and complete the Appointment of Representative Form, then send it to the Plan. You also have the right to hire a lawyer. |
Note: If you do not agree with the decision Passport Advantage makes, you can make an appeal. Please see your Evidence of Coverage for more details. |
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How to make an appeal: |
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| CALL | 1-800-578-0603, then press 1 (TTY users call 1-800-648-6056) |
| WRITE | Passport Advantage Member Services, P.O. Box 153098, Tampa, FL 33684 |
| OTHER OPTIONS | In some situations, you may ask your doctor or other provider to make an appeal for you. Ask someone to act on your behalf. To name someone as your representative, please download and complete the Appointment of Representative Form, then send it to the Plan. You also have the right to hire a lawyer. |
Note: If our Plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process. Please see your Evidence of Coverage for more details about the appeals process. |
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For More Information
You can learn more about coverage determinations, appeals and grievances by reading Section 9 in our Evidence of Coverage.
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