What are Grievances and Appeals?

How and who can file a Grievance?

• As a member of our plan, you may file a grievance
• You may appoint someone on your behalf to file a grievance
• You can file a grievance through our e-mail box address:  GandA@centersplan.com
• You may file a grievance through our fax number: 347-505-7089
• You may call 718-215-7000 Ext. 3792
• You may file a grievance through the mail. You may mail your grievance to:

Centers Plan for Healthy Living
75 Vanderbilt Avenue
Staten Island, NY 10304
Attention: Grievance and Appeals Department

(Please make sure to provide your name, CPHL ID number, Medicare MBI Number or Medicare number and the nature of your complaint. Make sure to sign and date your grievance)

• Contacting our member services at 1-877-940-9330 (or TTY call 711) 7 days a week, 8AM-8PM

What is a Grievance?

A grievance is an expression of dissatisfaction that you make if you have a complaint or problem that does not involve payment or services by Centers Plan for Healthy Living or a contracted Medical provider. Examples of a grievance are:

• Quality issues
• Waiting times on the phone or at the doctor’s office
• Problems with a network pharmacy
• Rudeness by the doctor’s or the plan staff

CPHL will send you a resolution letter describing how we resolved your grievance. We will resolve your grievance within the following timeframe:

• Standard: Grievances will be decided within thirty (30) calendar days from receipt of grievance.
• Expedited: When a delay would significantly increase the risk to your health, a decision will be made within 72 hours from receipt of grievance.
• Extension: We may request up to 14 additional days to review your complaint if we need more information and the delay is in your interest. We will notify you in advance if we require more time.

Quality of Care Complaints

For quality of care complaints, you may also file a written complaint to Livanta, an independent Quality Improvement Organization (QIO) that is contracted with the Centers for Medicare and Medicaid Services to review quality complaints from Medicare beneficiaries. For example, if you believe your pharmacist provided the incorrect dose of a prescription, you may file a complaint with CPHL, QIO or both.

You may contact Livanta at:

Livanta
BFCC-QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701
866-815-5440
833-868-4056 (fax)
866-868-2289 (TTY)

Grievance Timeframe

You may file a grievance within sixty (60) calendar days of the date the circumstance giving rise to the grievance. The sixty (60) day limit may be extended for good cause.

Expedited Grievance

You have the right to request that a decision made by the plan which you are in disagreement be “fast reviewed” or expedited. We will acknowledge your grievance within twenty-four (24) hours of receipt and within three (3) calendar days we will notify you in writing with the resolution.

APPEAL:

What is an Appeal?

Is a disagreement that you have about a decisions the plan made regarding a service, payment for a service of amount you must pay for a service.

Appeal Timeframe

You may file an appeal within sixty-five (65) calendar days of the date of the initial plan determination. The sixty-five (65) day may be extended for good cause.

Expedited Appeal

You have the right to request that a decision be expedited if a standard decision would seriously jeopardize your life, health or your ability to regain maximum function. The plan or your Primary Care Physician will issue a decision as quickly as possible, but no later than seventy-two (72) hours after receiving the request.

How can you can file a Grievance or an Appeal?

As a member of our plan, you may file a grievance and/or appeal by:

You or your designee may file an appeal in writing, e-mail or by contacting our member services.

• Calling our member services at 1-877-940-9330 (or TTY 711) 7 days a week, 8AM-8PM
• E-mail address : GandA@centersplan.com
• Call 718-215-7000 Ext. 3792
• Fax number: 347-505-7089
• Mailing address:

Centers Plan for Healthy Living Advantage Care HMO
75 Vanderbilt Avenue
Staten Island, NY 10304
Attention: Grievance and Appeals Department

As a plan member, you may request the number of grievances, appeals and exceptions filed with the plan, by contacting our Grievances and Appeals Department as follows:

How to Appoint a Representative – Last updated 03/07/19

CMS Appointment of Representative Form  – Last updated 07/2023

CMS Appointment of Representative Form -Spanish – Last updated 07/2023

CMS Appintment of Representative Form- Large Print – Last updated 07/2023

Medicare Beneficiary Complaint Form

You may also submit feedback about your Medicare health and prescription drug plan directly to Medicare by completing the form at the link below.     If you have urgent concerns, call 1-800-633-4227, or TTY/TDD users call 1-877-486-2048.   https://www.medicare.gov/MedicareComplaintForm/home.aspx

The Medicare Beneficiary Ombudsman

The Medicare Beneficiary Ombudsman helps you with complaints, grievances and appeals and information requests about Medicare.  You may contact the ombudsman at the link below.

https://www.medicare.gov/claims-appeals/your-medicare-rights/get-help-with-your-rights-protections