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Appeals and Grievances

What if you have a problem?

If you have a problem or concern, you should call Member Services at 1-800-450-1166 (TTY/TDD 711), 8 a.m. to 8 p.m., 7 days a week.

Appeals

Important information about your appeals rights

How soon must you file an appeal?

You must file the appeal request within 60 calendar days of the date on your denial letter. You may file your request by mail, fax, or phone. We may give you more time to file if you have a good reason. You can look at your Evidence of Coverage, Chapter 9 (PDF — December 19, 2019) for more information on how to file an appeal. You can also contact Member Services.
There are two kinds of appeals related to Medical Services and Non-Prescription Drugs:
  1. Standard appeal: You have the right to appeal if you don't agree with a decision we make about services or payment. We will review our decision and let you know what we decide. You will get a written answer on a standard appeal 30 calendar days after we get your appeal. Our decision might take longer if you ask for an extension or if we need more information about your case. We will tell you if we're taking extra time and will explain why more time is needed. If your appeal is for payment of a service you have already received, we will give you a written answer within 60 calendar days.
  2. Fast appeal: You will get an answer within 72 hours after we get your fast appeal. You can ask for a fast appeal if you or your doctor believe your health could be harmed by waiting up to 30 calendar days for a decision.
We will give you a fast appeal if a doctor asks for one for you or supports your request. If you ask for a fast appeal without support from a doctor, we will decide if your request requires a fast appeal. If we don't give you a fast appeal, we'll give you an answer within 30 calendar days.
There are two kinds of appeals related to Prescription Drugs:
  1. Standard appeal: You have the right to appeal if you don't agree with a decision we make about services or payment. We will review our decision and let you know what we decide. You will get a written answer on a standard appeal 7 calendar days after we get your appeal. Our decision might take longer if you ask for an extension or if we need more information about your case. We will tell you if we're taking extra time and will explain why more time is needed. If your appeal is for reimbursement of a drug you have already received, we will give you a written answer within 14 calendar days.
  2. Fast appeal: You will get an answer within 72 hours after we get your fast appeal. You can ask for a fast appeal if you or your doctor believe your health could be harmed by waiting up to 30 calendar days for a decision.

How to ask for an appeal with Keystone First VIP Choice:

Step 1: You, your authorized representative, or your doctor must ask us for an appeal. Your written request must include:

  • Your name;
  • Your address;
  • Your Member ID number;
  • Your reasons for appealing; and
  • Your medical records, doctor's letter, or other information that proves why you need the item or service. Call your doctor if you need this information.
You can ask to see the medical records and other documents we used to make our decision before or during the appeal and a copy of the guidelines we used to make our decision, at no cost to you.

Step 2: Mail, Fax or call us.

For a standard appeal:
Mail:
Keystone First VIP Choice
Attn: Medicare Appeals and Grievances
P.O. Box 80109
London, KY 40742-0109
Phone Number: 1-800-450-1166 (TTY/TDD 711)
Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.
For a fast appeal:
Telephone: 1-800-450-1166 (TTY/TDD 711)
Fax: 1-855-221-0046

What happens next?

If you ask for an appeal and we continue to deny your request for a service or payment of a Medicare-covered service, we will send you a written decision and forward your case to the Medicare Independent Review Entity (IRE). If the IRE denies your request, the written decision will explain if you have additional appeal rights.

Grievances

A grievance is a complaint. It does not involve problems related to:

  • Approving or paying for Medicare Part C and Medicare Part D drugs.
  • Medical care or services.
  • Having to leave the hospital too soon.
  • Skilled nursing facility (SNF), home health agency (HHA), or comprehensive rehabilitation facility (CORF) services ending too soon.

What types of problems would lead you to file a grievance?

  • You have problems with the service you get from Member Services.
  • You feel that you are being encouraged to leave (disenroll from) the plan.
  • You do not agree with our decision not to give you a "fast" decision or a "fast" appeal.
  • We don't give you a decision within the required time frame.
  • We don't give you required notices.
  • You believe our notices and other written materials are hard to understand.
  • You feel that you wait too long for prescriptions to be filled.
  • You experience rude behavior by network pharmacists, physicians, or providers. This includes staff in pharmacies, physician offices, or hospitals.
  • We fail to give your case to the independent review entity. You do not get a decision on time because of this.
  • You do not feel you got the best medical care or services you could get. This includes care during a hospital stay.
  • You feel that you wait on the phone, in the waiting room, or in the exam room too long.
  • You have a problem getting an appointment when you need it. You wait too long for them.
  • The doctor's offices, clinics, or hospitals are not clean or in good condition.

Contact information for appeals and grievances

Mailing address:

Keystone First VIP Choice (HMO SNP)

Attn: Medicare Appeals and Grievances
P.O. Box 80109
London, KY 40742-0109

Phone: 1-800-450-1166 (TTY/TDD 711), 8 a.m. to 8 p.m., 7 days a week.
Fax: 1-855-221-0046

Important forms

Appointment of Representative (AOR) form (PDF) — A request can be made by a family member, friend, or other party. This person must show legal authority, such as a medical power of attorney.

Download the AOR form (PDF).

Other important information

You can see a total number of grievances, appeals, and exceptions filed with our plan. You can do this by contacting the Appeals and Grievances Unit. See the contact information above.

You are able to file a grievance or provide feedback directly to Medicare about our plan using the Medicare Feedback and Complaint Form.

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