Grievances

Member Grievances
Who Can File a Grievance?
A grievance may be filed by any of the following:

• You may file a grievance.
• Someone else may file the grievance for you on your behalf.

You may appoint an individual to act as your representative to file the grievance for you by following the steps below:

• Provide your Medicare Advantage health plan with your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: “I [your name] appoint [name of representative] to act as my representative in requesting a grievance from your Medicare Advantage health plan and/or CMS regarding the denial or discontinuation of medical services.”
• Provide your name, address and phone number and that of your representative, if applicable.
• You must sign and date the statement.
• Your representative must also sign and date this statement.
• You must include this signed statement with your grievance.

What Is a Grievance?

A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your Medicare Advantage health plan or a Contracting Medical Provider. For example, you would file a grievance if: you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor’s office.

When Can a Grievance Be Filed?

You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance. There is no filing limit for complaints concerning quality of care. Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

Expedited Grievance

You have the right to request a fast review or expedited grievance if you disagree with your Medicare Advantage health plan’s decision to invoke an extension on your request for an organization determination or reconsideration, or your Medicare Advantage health plan’s decision to process your expedited request as a standard request. In such cases, your Medicare Advantage health plan will acknowledge your grievance within twenty-four (24) hours of receipt and notify you in writing of your Medicare Advantage health plan’s conclusion within three (3) calendar days.

Where Can a Grievance Be Filed?

A grievance may be filed in writing directly to us or contacting Customer Service at the telephone number (or the TTY number for the hearing impaired) listed in the Summary of Benefits, 8 a.m. to 8 p.m., local time, 7 days a week. You may also contact Customer Service and request the facsimile number for Appeals and Grievances.

Why File a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

You can file your grievance with Physicians Health Choice by calling Customer Service at 1-866-550-4736 (TTY 711), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, or mail your written complaint to:

Physicians Health Choice
Attn: Grievance Dept.
P.O. Box 690670
San Antonio, TX 78269-0670

For more information on Grievances, refer to your Evidence of Coverage.

You may also file a complaint with Medicare. Click here to submit your complaint online.