If you are a member of Optima Medicare Preferred Plus (PPO) or Optima Medicare Value Plus (PPO), and you have a concern about your health plan, the quality of your care or your coverage for certain services, you may follow an established process to resolve your concern. You cannot be disenrolled from Optima Medicare plans or penalized in any way if you make a complaint.
What is a Grievance?
A grievance is any complaint, other than one that involves a request for an initial determination or an appeal.
An appeal is defined as any of the procedures that deal with the review of adverse coverage determinations made by the Part D plan sponsor on the benefits under a Part D plan you believe you are entitled to receive, including a delay in providing or approving the drug coverage (when a delay would adversely affect your health), or on any amounts you must pay for the drug coverage. These procedures include redeterminations by the Part D plan sponsor, reconsiderations by the independent review entity (IRE), Administrative Law Judge (ALJ) hearings, reviews by the Medicare Appeals Council (MAC), and judicial reviews.
What types of problems might lead to your filing a grievance?
- Problems with the service you receive from Member Services.
- If you feel that you are being encouraged to leave (disenroll from) the Plan.
- If you disagree with our decision not to give you a “fast” decision or a “fast” appeal.
- We don’t give you a decision within the required time frame.
- We don’t give you required notices.
- You believe our notices and other written materials are hard to understand.
- Waiting too long for prescriptions to be filled.
- Rude behavior by network pharmacists or other staff.
- We don’t forward your case to the Independent Review Entity if we do not give you a decision on time.
Who may file a grievance?
You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative.
If you would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on your behalf, you and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request. The form can be found at the following web address: http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf. Or, you can call Member Services at 1-800-927-6048 (TTY/TDD 1-800-828-1120) and we will send this form to you. Send the completed form and your request to:
Optima Medicare (PPO)
Appeals Department
P. O. Box 62876
Virginia Beach, VA 23466-2876
Filing a grievance with our Plan
If you have a complaint, you or your representative may call 1-800-927-6048 (TTY/TDD 1-800-828-1120). We will try to resolve your complaint over the phone. If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints.
The grievance must be submitted within sixty (60) days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than thirty (30) days after receiving your complaint. We may extend the time frame by up to fourteen (14) days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.
Informal Complaints
An informal complaint may be appropriate if you want to make us aware of a problem or a concern with care you received from one of our providers but you don’t necessarily want the information shared with your provider, or you do not want your name used. Please follow these steps to file an informal complaint:
- Call Member Services at 1-800-927-6048 (TTY/TDD 1-800-828-1120) and let us know about your concern(s). You should call as soon as possible within sixty (60) calendar days of the date of the occurrence(s).
- The Member Services representative may ask you for additional information so that we may research the issue. We won’t contact your provider and you don’t have to give us your name. The information that you provide us about your complaint will be used for training and education purposes only.
- We may follow up your phone call with a letter written to you stating that we received and processed your grievance as an informal complaint.
Formal Written Complaints
You may choose to file a formal written complaint. Formal complaints are thoroughly investigated by contacting all involved parties, including the provider of your service and obtaining all information regarding the issues. A formal complaint should be made in writing as soon as possible within sixty (60) calendar days of the occurrence. Please follow these steps to file a formal written complaint:
- Formal complaints should always be in writing. Call Member Services at 1-800-927-6048 (TTY/TDD 1-800-828-1120) for a copy of instructions and complaint forms. Tell Member Services if you need help with writing your complaint, or if for some reason you are unable to file a written complaint. You may also obtain complaint forms and instructions by downloading and printing them from our website www.optimahealth.com.
- Once you complete the written complaint form, it should be mailed to:
Optima Medicare (PPO)
Appeals Department
P. O. Box 62876
Virginia Beach, VA 23466-2876.
You may also fax your written complaint form to Optima Health at 757-687-6232 or toll-free 1-866-472-3920.
- You will receive a letter notifying you that your compliant has been received and about how long it will take to investigate the issues presented. Time frames for resolving complaints vary by the type of complaint. If your complaint is clinically urgent, the complaint will be addressed no later than one (1) business day after we receive all necessary information, including any additional information we request from you and any information we request from your provider. We will let you know how your complaint is resolved no later than seventy-two (72) hours from receipt of an urgent complaint. If your complaint is not clinically urgent, we will process your complaint and let you know how your complaint is resolved within thirty (30) calendar days of the date we receive your written complaint.
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.
You have the right to request a fast review or expedited grievance if you disagree with Optima Medicare’s decision to invoke an extension on your request for an organization determination or reconsideration, or the Plan's decision to process your expedited request as a standard request. In such cases, Optima Medicare will acknowledge your grievance within twenty-four (24) hours of receipt and notify you in writing of the Plan's conclusion within three (3) calendar days.
Fast Grievances
In certain cases, you have the right to ask for a “fast grievance,” meaning we will answer your grievance within twenty-four (24) hours.
Complaints and Appeals about your Part D Prescription Drug(s)
Initial Determinations
The initial determination we make is the starting point for dealing with requests you may have about covering a Part D drug you need, or paying for a Part D drug you already received. Initial decisions about Part D drugs are called "coverage determinations." With this decision, we explain whether we will provide the Part D drug you are requesting, or pay for the Part D drug you already received.
The following are examples of requests for initial determinations:
- You ask us to pay for a prescription drug you have received.
- You ask for a Part D drug that is not on your plan sponsor's list of covered drugs (called a "formulary"). This is a request for a "formulary exception."
- You ask for an exception to our utilization management tools - such as prior authorization, dosage limits, or quantity limits. Requesting an exception to a utilization management tool is a type of formulary exception.
- You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a "tiering exception.”
The Evidence of Coverage has detailed information on how to request reimbursement for a drug that you have already paid for and received.
What is an exception?
An exception is a type of initial determination (also called a “coverage determination”) involving a Part D drug. You or your doctor may ask us to make an exception to our Part D coverage rules in a number of situations.
- You may ask us to cover your Part D drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan.
- You may ask us to waive coverage restrictions or limits on your Part D drug. For example, for certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
- You may ask us to provide a higher level of coverage for your Part D drug. If your Part D drug is contained in our third tier, non-preferred brand Part D drug tier, you may ask us to cover it at the cost-sharing amount that applies to drugs in the second tier, preferred brand Part D drug tier instead. This would lower the co-payment amount you must pay for your Part D drug.
Your doctor must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor should be sent to us with the exception request.
If we approve your exception request, our approval is valid for the remainder of the Plan year, so long as your doctor continues to prescribe the Part D drug for you and it continues to be safe for treating your condition. If we deny your exception request, you may appeal our decision.
Note: If we approve your exception request for a Part D non-formulary drug, you cannot request an exception to the co-payment or coinsurance amount we require you to pay for the drug.
Who may ask for an initial determination?
You, your prescribing physician, or someone you name may ask us for an initial determination. The person you name would be your “appointed representative.” You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under State law to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative. You and your “appointed representative” need to complete the form (or a written equivalent) that can be found at the following web address: http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf. Or, you can call Member Services at 1-800-927-6048 (TTY/TDD 1-800-828-1120) and we will send this form to you. Send the completed form to:
Optima Medicare (PPO)
Pharmacy Authorizations
4417 Corporation Lane
Virginia Beach, VA 23462
You also have the right to have a lawyer act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.
Asking for a “standard" or "fast" initial determination
A decision about whether we will give you, or pay for, the Part D drug you are requesting can be a “standard" decision that is made within the standard time frame or it can be a “fast" decision that is made more quickly. A fast decision is also called an “expedited" decision.
Asking for a standard decision
To ask for a standard decision for a Part D drug you, your doctor, or your representative should fax, or write us at the numbers or address listed at the end of this document, submitting the form located at the following web address: http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/ModelCoverageDeterminationRequestForm.pdf. Or, you can call Member Services at 1-800-927-6048 (TTY/TDD 1-800-828-1120) and we will send this form to you.
Asking for a fast decision
You may ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. (Fast decisions apply only to requests for benefits that you have not yet received. You cannot get a fast decision if you are asking us to pay you back for a benefit that you already received.)
Be sure to ask for a “fast or “expedited” review. If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.
If you ask for a fast decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a “fast grievance.” You have the right to file a fast grievance if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast initial determination, we will give you a standard decision.
What happens when you request an initial determination?
- For a standard initial determination about a Part D drug (including a request to pay you back for a Part D drug that you have already received), we must give you our decision no later than seventy-two (72) hours after we receive your request, but we will make it sooner if your request is for a Part D drug that you have not received yet and your health condition requires us to. However, if your request involves a request for an exception (including a formulary exception, tiering exception, or an exception from utilization management rules – such as prior authorization, dosage limits, or quantity limits, we must give you our decision no later than seventy-two (72) hours after we receive your physician's "supporting statement" explaining why the drug you are asking for is medically necessary. If you have not received an answer from us within seventy-two (72) hours after we receive your request (or your physician's supporting statement if your request involves an exception), your request will automatically go to Appeal Level 2.
- For a fast initial determination about a Part D drug that you have not yet received, we will give you our decision within twenty-four (24) hours after you or your doctor ask for a fast review. We will give you the decision sooner if your health condition requires us to. If your request involves a request for an exception, we will give you our decision no later than twenty-four (24) hours after we have received your physician's "supporting statement," which explains why the drug you are asking for is medically necessary. If we decide you are eligible for a fast review and you have not received an answer from us within twenty-four (24) hours after receiving your request (or your physician's supporting statement if your request involves an exception), your request will automatically go to Appeal Level 2.
What happens if we decide completely in your favor?
- For a standard decision about a Part D drug (including a request to pay you back for a Part D drug that you have already received), we must cover the Part D drug you requested as quickly as your health requires, but no later than seventy-two (72) hours after we receive the request. If your request involves a request for an exception, we must cover the Part D drug you requested no later than seventy-two (72) hours after we receive your physician's "supporting statement." If you are asking us to pay you back for a Part D drug that you already paid for and received, we must send payment to you no later than thirty (30) calendar days after we receive the request (or supporting statement if your request involves an exception).
- For a fast decision about a Part D drug that you have not yet received, we must cover the Part D drug you requested no later than 24 hours after we receive your request. If your request involves a request for an exception, we must cover the Part D drug you requested no later than twenty-four (24) hours after we receive your physician's "supporting statement."
What happens if we decide against you?
If we decide against you, we will send you a written decision explaining why we denied your request. If an initial determination does not give you all that you requested, you have the right to appeal the decision.
Appeal Level 1: Appeal to the Plan
An appeal to the plan about a Part D drug is also called a plan "redetermination."
Who may file your appeal of the initial determination?
If you are appealing an initial decision about a Part D drug, you or your representative may file a standard appeal request, or you, your representative, or your doctor may file a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within sixty (60) calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.
How to file your appeal?
- Asking for a standard appeal: To ask for a standard appeal about a Part D drug, a signed, written appeal request must be sent to:
Optima Medicare (PPO)
Pharmacy Authorizations
4417 Corporation Lane
Virginia Beach, VA 23462
- Asking for a fast appeal: If you are appealing a decision we made about giving you a Part D drug that you have not received yet, you and/or your doctor will need to decide if you need a fast appeal. You, your doctor, or your representative may ask us for a fast appeal by calling, faxing, or writing us at:
Optima Medicare (PPO)
Pharmacy Authorizations
4417 Corporation Lane
Virginia Beach, VA 23462
Toll-free Fax: 1-800-750-9692
Phone: 1-800-927-6048
TTY/TDD: 1-800-828-1120
Outside of regular weekday business hours, please call the Optima Health After Hours Department at 757-552-7250 or 1-800-394-2237 to request a fast appeal for a Part D drug. Requests received outside of regularly scheduled business hours will receive priority attention the next business day. Be sure to ask for a "fast" or "72-hour" review.
Remember, if your doctor provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically give you a fast appeal. If you ask for a fast decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a “fast grievance.” You have the right to file a fast grievance if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast appeal, we will give you a standard appeal.
How soon must we decide on your appeal?
- For a standard decision about a Part D drug that includes a request to pay you back for a Part D drug you have already paid for and received, we will give you our decision within seven (7) calendar days of receiving the appeal request. We will give you the decision sooner if you have not received the drug yet and your health condition requires us to. If we do not give you our decision within seven calendar days, your request will automatically go to Appeal Level 2.
- For a fast decision about a Part D drug that you have not yet received, we will give you our decision within seventy-two (72) hours after we receive the appeal request. We will give you the decision sooner if your health condition requires us to. If we do not give you our decision within seventy-two (72) hours, your request will automatically go to Appeal Level 2.
What happens if we decide completely in your favor?
- For a standard decision about a Part D drug (including a request to pay you back for a Part D drug that you have already received), we must cover the Part D drug you requested as quickly as your health requires, but no later than seven (7) calendar days after we receive the request. If you are asking us to pay you back for a Part D drug that you already paid for and received, we must send payment to you no later than thirty (30) calendar days after we receive the request.
- For a fast decision about a Part D drug that you have not yet received, we must cover the Part D drug you requested no later than seventy-two (72) hours after we receive your request.
Appeal Level 2: Independent Review Entity (IRE)
At the second level of appeal, your appeal is reviewed by an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this entity.
How to file your appeal?
If you asked for Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the IRE. If you choose to appeal, you must send the appeal request to the IRE. The decision you receive from the plan (Appeal Level 1) will tell you how to file this appeal, including who can file the appeal and how soon it must be filed.
If you asked for payment for Part C medical care or services, and we did not rule completely in your favor at Appeal Level 1, your appeal is automatically sent to the IRE.
How soon must the IRE decide?
The IRE has the same amount of time to make its decision as the plan had at Appeal Level 1.
If the IRE decides completely in your favor:
The IRE will tell you in writing about its decision and the reasons for it.
- For a decision to pay you back for a Part D drug you already paid for and received, we must send payment to you within thirty (30) calendar days from the date we receive notice reversing our decision.
- For a standard decision about a Part D drug you have not yet received, we must cover the Part D drug you asked for within seventy-two (72) hours after we receive notice reversing our decision.
- For a fast decision about a Part D drug you have not yet received, we must cover the Part D drug you asked for within twenty-four (24) hours after we receive notice reversing our decision.
Appeal Level 3: Administrative Law Judge (ALJ)
If the IRE does not rule completely in your favor, you or your representative may ask for a review by an Administrative Law Judge (ALJ) if the dollar value of the Part D drug you asked for meets the minimum requirement provided in the IRE’s decision. During the ALJ review, you may present evidence, review the record (by either receiving a copy of the file or accessing the file in person when feasible), and be represented by counsel.
How to file your appeal?
The notice from the IRE will explain how and where to file an appeal with the ALJ. The request must be filed in writing within sixty (60) calendar days of the date you were notified of the decision made by the IRE (Appeal Level 2). You can use the form at the following web address to file your appeal with the ALJ: http://www.cms.hhs.gov/cmsforms/downloads/CMS20034AB.pdf. Or, you can call Member Services at 1-800-927-6048 (TTY/TDD 1-800-828-1120) and we will send this form to you.
The ALJ will not review your appeal if the dollar value of the requested Part D drug does not meet the minimum requirement specified in the IRE's decision. If the dollar value is less than the minimum requirement, you may not appeal any further.
How soon will the Judge make a decision?
The ALJ will hear your case, weigh all of the evidence, and make a decision as soon as possible.
Appeal Level 4: Medicare Appeals Council (MAC)
If the ALJ does not rule completely in your favor, you or your representative may ask for a review by the Medicare Appeals Council (MAC).
How to file your appeal?
The request must be filed with the MAC within sixty (60) calendar days of the date you were notified of the decision made by the ALJ (Appeal Level 3). The MAC may give you more time if you have a good reason for missing the deadline. The decision you receive from the ALJ will tell you how to file this appeal, including who can file it.
How soon will the Council make a decision?
The MAC will first decide whether to review your case (it does not review every case it receives). If the MAC reviews your case, it will make a decision as soon as possible. If it decides not to review your case, you may request a review by a Federal Court Judge (see Appeal Level 5). The MAC will issue a written notice explaining any decision it makes. The notice will tell you how to request a review by a Federal Court Judge.
Appeal Level 5: Federal Court
You have the right to continue your appeal by asking a Federal Court Judge to review your case if the amount involved meets the minimum requirement specified in the Medicare Appeals Council's decision, you received a decision from the Medicare Appeals Council (Appeal Level 4), and:
- The decision is not completely favorable to you, or
- The decision tells you that the MAC decided not to review your appeal request.
How to file your appeal
In order to request judicial review of your case, you must file a civil action in a United States district court within sixty (60) calendar days after the date you were notified of the decision made by the Medicare Appeals Council (Appeal Level 4). The letter you get from the Medicare Appeals Council will tell you how to request this review, including who can file the appeal.
Your appeal request will not be reviewed by a Federal Court if the dollar value of the requested Part D drug does not meet the minimum requirement specified in the MAC’s decision.
How soon will the Court make a decision?
The Federal Court Judge will first decide whether to review your case. If it reviews your case, a decision will be made according to the rules established by the Federal judiciary.
If the Court decides against you
You may have further appeal rights in the Federal Courts.
Favorable Decisions by the ALJ, MAC, or a Federal Court Judge
This section explains what we must do if our initial decision denying what you asked for is reversed by the ALJ, MAC, or a Federal Court Judge.
- For a decision to pay you back for a Part D drug you already paid for and received, we must send payment to you within thirty (30) calendar days from the date we receive notice reversing our decision.
- For a standard decision about a Part D drug you have not yet received, we must cover the Part D drug you asked for within seventy-two (72) hours after we receive notice reversing our decision.
- For a fast decision about a Part D drug you have not yet received, we must cover the Part D drug you asked for within twenty-four (24) hours after we receive notice reversing our decision.
Evidence of Coverage
For more detailed information and a description of the processes, refer to your Evidence of Coverage.
Who to contact about general information or information about the number of Appeals, Grievances and/or Exceptions filed with Optima Medicare?
Optima Medicare (PPO)
Appeals Department
P.O. Box 62876
Virginia Beach, VA 23466-2876
Fax: 757-687-6232 or Toll-free Fax: 1-866-472-3920
Phone: 757-687-6404 or Toll-free Phone: 1-800-927-6048
TTY/TDD: 1-800-828-1120