Grievances & Appeals - Community Health Plan of Washington - Medicare Advantage

Grievances & Appeals

We take your concerns seriously and consider them opportunities to improve service and care. As a member, you have the right to voice a complaint if you have a problem or concern about the care you receive with our providers or the health care coverage of our plan.

The following is an overview of the procedures to file an Appeals, Coverage Determinations, and Grievances. For complete information, please read our CHPW Medicare Advantage Appeals & Grievances Policy Handbook in English or Spanish.

If you are enrolled in our MA Special Needs Plan (014), please read the Appeals and Grievances booklet for your plan in English or Spanish.

You always have the option to contact CMS directly with your concerns by calling them at 1-800-MEDICARE, or through their website at www.medicare.gov/MedicareComplaintForm/home.aspx

Grievances

A grievance is a complaint. You can file a grievance with your health plan if you are not happy with the quality of care or services you receive at our clinics, you have problems getting care, or billing issues. For example, you would file a grievance if you have concerns about things such as:

  • the quality of your care
  • waiting times for appointments or in the waiting room
  • your provider’s behavior
  • the ability to reach someone by phone or get the information you need
  • the cleanliness or condition of your provider’s office
  • the courtesy of services we provide you

Community Health Plan of Washington will keep your grievance private. We will let you know we received your grievance within two business days and will try to take care of your grievance right away. We will resolve your grievance within 45 days and let you know what happened.

Appeals and Coverage Determinations

An appeal is when you want us to reconsider a decision we have made about what benefits your plans cover or what we will pay. You can request an appeal when a service or referral has been denied. For example, you might appeal if you think we:

  • will not approve payment for care you believe should be covered
  • are stopping payment for care you need
  • or have not paid for a particular medical procedure or service you think should be covered

A coverage determination is the first step you take in requesting a ruling on a Part D prescription drug benefit. When we make a coverage determination, we are making a decision whether or not to pay for a Part D drug and what your share of the cost is.

You can also request a coverage determination on a Part D prescription drug through the appeal process.

You can find the Part D coverage determination form, redetermination forms, and exception request form here.

Appeals Process

If you are submitting an appeal, certain steps will be followed to process your request. If the final decision in the appeal process agrees with our initial action, you may need to pay for services you received during the appeal process. Below are the steps in the appeal process:

Step 1: CHPW Medicare Advantage Appeal
You have 60 calendar days after the date of CHPW Medicare Advantage’s denial letter to ask for an appeal. You or your representative may request an appeal or may submit information about your case over the phone, in person, in writing, or by fax to 206-613-8983. Within 72 hours, we will let you know in writing that we got your appeal.

CHPW Medicare Advantage can help you file your appeal. If you need help filing an appeal, call Customer Service at 1-800-440-1561 (TTY Relay: 711)
You may choose someone, including a lawyer or provider, to represent you and act on your behalf. You must sign a consent form allowing this person to represent you. CHPW Medicare Advantage does not cover any fees or payments to your representatives. That is your responsibility.

Before or during the appeal, you or your representative may look at your file, medical records, or other documents considered in the appeal. If you want copies of the guidelines we used to make our decision, we can give them to you at no charge. We will keep your appeal private. We will send you our decision in writing within 14 calendar days, unless we tell you we need more time. Our review will not take longer than 28 calendar days, unless you give us written consent.

Step 2: Independent Review
If CHPW Medicare Advantage upholds the denial decision after reconsideration, your appeal will be automatically sent to an Independent Review Entity (IRE). The IRE will process the appeal reconsideration within 30 calendar days.
Step 3: Medicare Appeals Council
If you do not agree with the decision from the IRE, you have 60 days to file for a hearing with an administrative law judge from the Office of Medicare Hearings and Appeals. You can only request this appeal if the denied amount in question is greater than or equal to $160. There is no limit to processing time.

If you do not agree with this decision, you can appeal a fourth time with the Medicare Appeals Councils. You have 60 calendar days to file, from the time you receive the appeal decision from the Office of Medicare Hearings and Appeals. There is no limit to process time.

If you do not agree with their decision, you have 60 calendar days to file an appeal with Federal District Court. You may only reach this level of appeal if the amount in question is greater than or equal to $1,630. You are responsible to pay any fees associated with appointing counsel or a lawyer to represent you.

How to File a Grievance Appeal or Coverage Determination

There are four ways to file any of these requests: by phone, by fax, in writing or in person. Click on your preferred method to learn where to submit your written or verbal requests.

By Phone:
Call Customer Service at 1-800-942-0247 (TTY Relay: 711) from 8:00 a.m. to 8:00 p.m., seven days a week.
By Fax:
Fax completed forms to 206-613-8983.
In Writing
Send your written request or form to:

Community Health Plan of Washington
Attn: CHPW Medicare Advantage Grievance Coordinator
1111 Third Avenue, Suite 400
Seattle, WA 98101. 

In Person
Deliver your request to:

Community Health Plan of Washington
1111 Third Avenue, Suite 400
Seattle, WA 98101.

To check the status of your appeal or coverage determination, contact customer service.

Notification Process

There are two kinds of requests: standard and expedited (faster). If you or your provider think to wait for a decision would put your health at risk, you may ask for an expedited request. If you think we need to look at any additional information, you must submit it to us quickly. We will review your request and make a decision with 72 hours (three calendar days). If we decide your health is not at risk, we will follow the regular time frame to make our decision.
Learn how long it takes to process each type of request below.

Grievances:

Standard grievance requests are typically decided upon within 30 calendar days from the date we receive your request but may be extended if additional information is needed. Grievances filed verbally are responded to verbally. Grievances filed in writing and all quality of care grievances are responded to in writing.

Decisions on Part D prescription drug standard grievance requests are made within 30 days.

Decisions on expedited grievances are made within 72 hours (three calendar days) of the receipt of the request. If we determine that the grievance should be standard instead, we will promptly call you with that decision and follow up with a written notice within two calendar days. Decisions on Part D expedited grievance requests are made within 24 hours.

Appeals:

Standard appeals are processed within 30 calendar days from the date we receive your request but may be extended to 44 calendar days if additional information is needed. You will receive notice of our decision in writing along with any supporting explanation.

Expedited appeals are processed within 72 hours (three calendar days). If we determine that your health is not at risk, we will follow the standard appeals process. We will promptly call you with that decision and follow up with a written notice within two calendar days.

Coverage Determinations:

Decisions on standard appeals for Part D prescription drug coverage determination are made within 7 calendar days from the date we receive your request.
Decisions on expedited appeals are made within 72 hours of the receipt of the appeal. If we determine that the appeal should be standard instead, we will promptly call you with that decision and follow up with a written notice within two calendar days.
Decisions on expedited appeals for Part D prescription drug coverage determination are made within 24 hours from the date we receive your request.

Information and Forms

Use the following forms to submit your grievance, appeal, or determination request.
Medical and Plan Forms  |  Prescription Drug Forms  |  Prior Authorization Information and Forms
To obtain an aggregate number of Appeals and Grievances filed with CHPW Medicare Advantage, please contact our Customer Service.
You can also learn more about what happened to formal complaints filed with CHPW Medicare Advantage by reading our current Appeals and Grievances Report.

Appointing a Representative

An appointed representative is a relative, friend, advocate, doctor, or another person whom you authorize to act on your behalf in obtaining a grievance, coverage determination or appeal. If you would like to appoint a representative, both you and your representative must complete the form below and mail it to Community Health Plan of Washington.
Appointment of Representative  |  Nombramiento de un Representante  |  Appointment of Representative (Large Print)

Medicare Beneficiary Ombudsman

The Medicare Beneficiary Ombudsman helps you with complaints, grievances, and information requests. This person is an advocate who helps with complaints and violation of rights. The Medicare Beneficiary Ombudsman makes sure information is available about the following:

  • What you need to know to make health care decisions that are right for you
  • Your rights and protections under Medicare
  • How you can get issues resolved

For more information, visit http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html.

DID YOU KNOW...?

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