As a member of our plan, you have the right to make a complaint (also called “filing a grievance”) for certain types of problems not related to benefits, coverage, or payment.
Here are some examples of problems that are handled through the grievance process:
If you have a grievance related to our plan’s medical care and services (Medicare Part C) or prescription drugs (Medicare Part D), we encourage you or your authorized representative to call our Member Services Department first at 1-844-294-6535. We are open from 8:00 a.m. – 5:00 p.m. local time, seven days a week, except for Thanksgiving and Christmas. TTY users should call 711. Calls to these numbers are free. We will try to resolve your complaint over the phone. If we cannot resolve your grievance over the phone or you do not want to call our plan, we have a formal procedure to review grievances.
These grievances must be submitted in writing to the following addresses or fax numbers:
Gold Kidney Health Plan
Attention: Appeals & Grievances Department
P.O. Box 285
Portsmouth, NH 03802
Phone: 844-294-6535
TTY Users: 711
Fax: 866-515-7869
Attention: Gold Kidney Appeals & Grievances Department
If you ask for a grievance by phone, we will send you a letter confirming what you told us.
For Part D Grievances (about Part D prescription drugs)
Mailing Address:
MedImpact
Attention: Appeals & Grievances Dept.
10181 Scripps Gateway Court
San Diego, CA 92131
Phone: 888-672-7206
Fax: 858-790-6060
You are not required to use our plan’s Grievance form, but we strongly urge you to do so. Call Member Services to obtain the Grievance form.All grievances must be submitted within 60 days after the event or incident. We will answer your grievance no later than 30 days after we receive it (sooner if your health requires it). If we need more information and a delay is in your interest or you request a delay, we can take 14 more days (44 days total) to give you an answer.
If you have a complaint about the quality of care you receive, you may file a grievance with your state’s QIO. In Arizona, the QIO is called Health Services Advisory Group (HSAG). You may contact HSAG at the following address, website, or phone number:
Address: Health Service Advisory Group 3133 East Camelback Road, Ste.100 Phoenix, AZ 85016-4545
Phone: 602-801-6600 Website: https://www.HSAG.com
Coverage decisions are decisions we make about your benefits or coverage or about the amount we will pay for Part C medical services or Part D drugs. A coverage decision about Part C medical services is called an “organization determination.” A coverage decision about Part D drugs is called a “coverage determination.” Coverage determinations and organization determinations are the first step in addressing problems you may have regarding medical or prescription drug benefits, coverage or payment amounts.
You, your prescribing physician, or someone you name may ask us for a coverage determination. Other persons may be authorized under state law to act on your behalf.
Asking for a “standard” or “fast” coverage determination or organization determination
To ask for a “standard” or “fast” decision for a Part D drug or Part C medical care, you, your doctor or your representative should call, fax or write to us at the addresses and numbers listed below under Part D Coverage Determinations or Part C Organization Determinations.
Phone: 1-844-294-6535
TTY Users: 711
Fax: 1-866-515-7869 Attention: Utilization Management Dept.
Mailing Address:
Gold Kidney Health Plan Inc.
Attention: Utilization Management Dept.
P.O. Box 285
Portsmouth, NH 03802
For a standard organization determination, we must give you our decision within 14 days after we receive your request. However, we may take up to 14 additional days if you ask for more time or if we need more information to help us with our decision. We will let you know in writing if we need extra time to make our decision.
If the standard organization determination deadlines could result in serious harm to your health, you can ask us for a “fast” or “expedited” organization determination. If your doctor tells us you need a fast organization determination, we will give you one automatically. For a fast organization requirement, we will answer your request within 72 hours. However, we may take up to 14 more days if you need more time to prepare for this review or we need additional information from you or your doctor.
For Part D Organization Determinations:
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