Grievance & Appeals

A “grievance” is the type of complaint you make that will not usually involve coverage or payment for prescription drugs included in Medicare prescription drug coverage benefits. Instead, the following types of problems might lead to you filing a grievance:

Quality of your medical care – unhappy with level of quality care received
Respecting your privacy – believe there was a lack confidentiality
Disrespect, poor customer service, or other negative behaviors – experienced rude or disrespectful interactions
Waiting times – extensive phone wait times or long pharmacy waits
Cleanliness – dissatisfaction with cleanliness in areas you receive care (MD Office/Pharmacy/etc)
Information you get from us – dissatisfaction with plan communication of information

To file a grievance, complete and submit the complaint form posted below. If someone is filing an appeal, grievance, or other action on your behalf, please make sure we have an Appointment of Representative Form (pdf) on file for that person.

You can make an “appeal” when you disagree with a decision to deny a request for health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if the plan doesn’t pay for a drug, item, or service you think you should be able to receive. To file an appeal, complete and submit the Member Appeal Form (pdf).

Medicare Appeals and Grievance Process

You may file an appeal or grievance pertaining to either medical coverage or Part D prescription drug coverage. For a complete description of our appeals and grievance process in a specific plan, please refer to the plan’s Evidence of Coverage (EOC)(pdf coming soon)

Request for Medical Service:
If you’re requesting a Medical Service, you’ll ask for a coverage decision (Organization Determination).

You can call us, fax or mail your request:

Call: 1.888.477.HOME (4663) TTY/TDD: 711

Fax: 1.315.870.7788

Mail:
Nascentia Health Plus
Coverage Determination
1050 West Genesee St
Syracuse, NY 13204

We’ll get back to you with a determination within:

  • 14 days for a standard request
  • 72 hours for an expedited request

If we do not approve your request for coverage, you can appeal our decision.

You can submit a complaint about Nascentia Health Plus Medicare Advantage directly to Medicare by calling 1-800-Medicare, or by submitting an online complaint directly to Medicare at https://www.medicare.gov/MedicareComplaintForm/home.aspx .

To obtain an aggregate number of grievances, appeals and exceptions filed with the plan, please call us at 1.888.477.HOME (TTY 711).

Hours of Operation 8am – 8pm, 7 days* a week
*October 1st – March 31st / Mon- Fri rest of the year

 

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