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Grievances and Appeals

You have the right to make a complaint if you have concerns or problems related to your coverage or care that you receive.

There are certain rules that MeridianComplete (Medicare-Medicaid Plan) must follow when we receive a complaint. There are also rules that explain what you have to do in order to file a complaint with MeridianComplete. Complaints can be filed by members, a member's authorized representative, and by physicians. MeridianComplete handles every complaint fairly and does not discriminate against anyone that files a complaint.

For more information about your Grievance and Appeal rights, see your Summary of Benefits, call MeridianComplete Member Services Department at 1-855-323-4578 (TTY 711), 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. 

"Appeals" and "Grievances" are the two different types of complaints you can make.

Appeal

An Appeal is the type of request you can make when you want MeridianComplete to reconsider and change a decision we have made about a service, benefit, or prescription that is covered or if we will pay for it. For example, you can file an appeal if:

  • MeridianComplete denies payment or coverage for services you think we should cover
  • MeridianComplete providers reduces or terminates services or benefits you have been receiving
  • You think we are ending coverage of a service or benefit too soon

Grievance

A Grievance is the type of complaint you can make if you have any other type of problem with MeridianComplete or one of our plan providers. For example, you can file a grievance if you have issues or concerns such as:

  • The quality of the medical care you receive
  • Waiting times for appointments
  • The way that doctors, office staff, pharmacies, or other providers treat you
  • Not being able to reach someone by phone or get the information you need

You have the right to get information from Meridian about the number of appeals, grievances, and exceptions that members have filed against our organization in the past. To receive this information, please call our Member Services department at 1-855-323-4578 (TTY 711), Monday - Friday from 8 a.m. - 8 p.m.

Medicare Part C (medical care) Appeals

For Medical Related Coverage and Services

Appeals you can file before you receive a service:

Standard Appeal about authorizing medical care

After we receive your Standard Appeal request, we have up to 30 calendar days to make a decision. We may extend the timeframe by up to 14 calendar days if you request an extension, or if we justify the need for additional information and the extension is in your best interest. To request a Standard Appeal, contact us by telephone or fax at the numbers listed below.

Expedited Appeal about authorizing medical care

If you or your doctor believes that waiting for a standard appeal decision (up to 30 calendar days) could seriously harm your health or your ability to function, you, your doctor, or your authorized representative can request a fast, or Expedited Appeal. After we receive and approve your Expedited Appeal request, we must make our decision as quickly as your health condition might requires, but no later than 72 hours after receiving your request. We may extend the timeframe by up to 14 calendar days if you request an extension, or if we justify the need for additional information and the extension is in your best interest. To request an expedited appeal, contact us by telephone or fax at the numbers listed below.

Appeals you can file after you receive a service:

Standard Post-Service Appeal about payment

After we receive your appeal request, we have 60 calendar days to reconsider our decision. If we find in your favor, we must issue payment within 60 calendar days of the date of receipt of your appeal request.

How to File a Part C Appeal

To request a Standard Appeal, you can:

Call MeridianComplete Member Services at 1-855-323-4578 (TTY 711), Monday - Sunday, 8 a.m. to 8 p.m. to request a Standard Appeal. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

To request an Expedited Appeal, please contact us by phone or by fax at the numbers listed below:

Phone: 1-855-323-4578 (TTY 711), Monday - Sunday, 8 a.m. to 8 p.m. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

Fax: 1-844-273-2671

Please include copies of any additional information that may be important to your Appeal, and mail/fax that information to the following address/fax number:

MeridianComplete
Appeals and Grievances
Medicare Operations
7700 Forsyth Blvd
St. Louis, MO 63105

You must submit an appeal request within 60 calendar days of the date on the written notice sent by MeridianComplete, with our answer to your coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to submit an appeal. Examples of good cause for missing the deadline may include:

  • If you had a serious illness that prevented you from contacting us
  • If MeridianComplete provided incorrect or incomplete information about the deadline for requesting an appeal

If you have questions about filing an Appeal, or if you would like to ask about the status of an Appeal, please contact Member Services at 1-855-323-4578 (TTY 711), Monday - Sunday, 8 a.m. to 8 p.m. for further information. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

If we deny any part of your Appeal, your Appeal information will be forwarded to an Independent Review Organization (IRO). The IRO is contracted with the Federal government and is not a part of MeridianComplete.

The IRO will review your Appeal case and make a decision about whether we must provide the denied benefit or payment.

If the IRO (also known as the IRE) denies your Appeal, you can Appeal to an Administrative Law Judge (ALJ) if the value of your appeal meets the minimum requirement. If the minimum requirement is met, you will be notified of your Appeal rights along with the decision from the IRO. If you are unhappy with the decision of the ALJ, you have the right to Appeal to the Medicare Appeals Council (MAC). You will be notified of your right to Appeal to the MAC when you receive your decision from the ALJ. Finally, if you are unhappy with the decision made by the MAC, you can Appeal to the Federal Court if the value of your Appeal meets the minimum requirement. If the minimum requirement is met, you will be notified of your Appeal rights along with the decision from the MAC.

Medicare Part C (medical care) Grievance

How to File a Part C Grievance:

MeridianComplete wants to hear from you if you have concerns or problems with covered services or the quality of care you receive as a member of our plan. If you would like to file a Grievance, please contact our Member Services Department at 1-855-323-4578 (TTY 711), Monday - Sunday, 8 a.m. to 8 p.m.On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

There are two types of grievances:

1. Standard grievance.

You may file a standard grievance over the phone by calling Member Services at 1-855-323-4578 (TTY 711), Monday - Sunday, 8 a.m. to 8 p.m.On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.

You can send your written complaint via mail or fax:

Mail:

MeridianComplete
Appeals and Grievances
Medicare Operations
7700 Forsyth Blvd
St. Louis, MO 63105
Fax: 1-844-273-2671

You can also submit a complaint directly to Medicare by using the Medicare Grievance Form.

Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.

We must notify you of our resolution about your Grievance no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request an extension, or if we justify the need for additional information and the extension is in your best interest.

2. Expedited grievance.

You may request an expedited grievance if you disagree with our decision in the following scenarios:

  • We deny your request for an expedited review of a request for medical care.
  • We deny your request for an Expedited Appeal of denied services.
  • We decide an extension is needed to review your request for medical care.
  • We decide an extension is needed to review your Appeal of denied medical services.

To file an Expedited Grievance, please call Member Services at 1-855-323-4578 (TTY 711), Monday - Sunday, 8 a.m. to 8 p.m. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. You may also fax your Expedited Grievance request to: 1-844-273-2671. We will review your request and notify you of our decision no later than 24 hours from receiving your request to file an Expedited Grievance. Please call Member Services at the phone number above with any questions or concerns about the Grievance and/or Appeals process.

To receive more detailed information on the grievances and appeals filed against MeridianComplete, please call Member Services at 1-855-323-45789 (TTY 711), Monday - Sunday, 8 a.m. to 8 p.m. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

If your complaint is about the quality of care you received, you may also complain to the Quality Improvement Organization (QIO):

If you are concerned about the quality of care you received, including care received during a hospital stay, you can also contact an independent organization called the QIO. The QIO will perform an external investigation of your concern in addition to the investigation that MeridianComplete will perform through our internal grievance process.

For example, if you believe you are being discharged from the hospital too soon, you may file a complaint with the QIO in addition to, or in place of, filing a complaint with MeridianComplete. MeridianComplete will cooperate with the QIO in resolving your complaint.

How to file a quality of care complaint with the QIO

Quality of care complaints filed with the QIO must be made in writing. You are not required to file a quality of care grievance with the QIO within a certain time period.

You can contact the Quality Improvement Organization in your State by using the information below:

Livanta LLC
BFCC-QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701-1105

Consumer Help Line: 1-888-524-9900 (TTY: 1-888-985-8775), Monday - Friday, 9 a.m. to 5 p.m., Saturday - Sunday, 11 a.m. to 3 p.m.

Medicare Part D (prescription drugs) Appeals

For Prescription-Drug Related Coverage

Appeals you can file before you receive a Part D drug:

Standard Appeal decision about authorizing Part D services:

After we receive your Appeal request, we have up to 7 calendar days to make a decision. We will notify you in writing of our decision as quickly as your health condition requires, but no more than 7 days after we receive your request.

Expedited Appeal decision about authorizing Part D services:

If you or your doctor believes that waiting for a Standard Appeal decision could seriously harm your health or your ability to function, you, your doctor, or your authorized representative can request a fast, or Expedited Appeal. After we receive and approve your Expedited Appeal request, we must make our decision as quickly as your health condition requires, but no later than 72 hours from receiving your request. If your request for an Expedited decision is denied, your Appeal with automatically be transferred to the timeframe for resolving Standard Appeals, as described above. To request an Expedited Appeal, contact us by telephone, or fax your request to the numbers listed below.

Appeals you can file after you receive a service:

How to File a Part D Appeal

To request a Standard Appeal, contact Member Services at 1-855-323-4578 (TTY: 711), Monday - Sunday from 8 a.m. - 8 p.m.

To request an Expedited Appeal, please contact us by phone or by fax at the numbers listed below:

Phone: 877-440-0175 (TTY: 711), Monday - Sunday from 8 a.m. - 8 p.m.
Fax: 313-324-1881- Attention Part D Appeals Coordinator

Please include copies of any additional information that may be relevant to your appeal and send or fax to the following address:

Part D Appeals Coordinator
MeridianComplete
MeridianRx
1 Campus Martius, Suite 750
Detroit, MI 48226

How to File a Part D (Pharmacy) Grievance

MeridianComplete wants to hear from you if you have concerns or problems with covered services or the quality of care you receive as a member of our plan. If you would like to file a Part D Grievance, please contact our Member Services department within 60 days of the event that triggered your Grievance.

A Standard Grievance may be initiated over the phone by calling Member Services at 1-855-323-4578 (TTY: 711), Monday - Friday, 8 a.m. to 8 p.m, on weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. A Standard Grievance may also be submitted by fax to 1-844-273-2671. A Standard Grievance may also be filed by mail and sent to:

MeridianComplete
Appeals and Grievances
Medicare Operations
7700 Forsyth Blvd
St. Louis, MO 63105

We must notify you of our resolution about your Grievance no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request an extension, or if we justify the need for additional information and the extension is in your best interest.

You are entitled to request an Expedited Part D Grievance of your complaint if you disagree with our decision in the following scenarios:

  • We deny your request for an expedited review of a request for Part D coverage.
  • We deny your request for an expedited review of an Appeal of denied Part D services.

If we deny any part of your Part D Appeal, you may request your information be forwarded to an Independent Review Organization (IRO). The IRO is contracted with the Federal government and is not a part of MeridianComplete. The IRO will review the Appeal case and make a decision whether we must provide the denied benefit.

If the IRO (also known as the IRE) denies your Appeal, you can Appeal to an Administrative Law Judge (ALJ) if the value of your Appeal meets the minimum requirement. If the minimum requirement is met, you will be notified of your Appeal rights along with the decision from the IRO. If you are unhappy with the decision of the ALJ, you have the right to Appeal to the Medicare Appeals Council (MAC). You will be notified of your right to Appeal to the MAC when you receive your decision from the ALJ. Finally, if you are unhappy with the decision made by the MAC, you can Appeal to the Federal Court if the value of your Appeal meets the minimum requirement. If the minimum requirement is met, you will be notified of your Appeal rights along with the decision from the MAC.

To file an Expedited Part D Grievance, please call Member Services or fax your expedited grievance request to 1-844-273-2671. We will review your request and notify you of our decision no later than 24 hours from receiving your Expedited Grievance. Call Member Services at the phone number above with any questions or concerns about the Grievance and/or Appeals process.

If your complaint is about the quality of care you received, you may also complain to the Quality Improvement Organization (QIO):

If you are concerned about the quality of a Part D benefit you received, you can also contact an independent organization called the QIO. The QIO will perform an external investigation your concern in addition to the investigation that MeridianComplete will conduct through our internal grievance process.

How to file a quality of care complaint with the QIO

Quality of care complaints filed with the QIO must be made in writing. You are not required to file a quality of care grievance with the QIO within a certain time period.

Livanta LLC
BFCC-QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701-1105

Consumer Help Line: 1-888-524-9900 (TTY: 1-888-985-8775), Monday - Friday, 9 a.m. to 5 p.m., Saturday - Sunday, 11 a.m. to 3 p.m.

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