Grievances

What is a Grievance?

A grievance is a complaint you make about us or one of our Plan providers, including a complaint concerning the quality of your care. This type of complaint does not involve payment or coverage disputes.

What types of problems might lead to your filing a grievance?

• Problems with the quality of the medical care you receive, including quality of care during a hospital stay.
• If you feel that you are being encouraged to leave (disenroll from) the Plan.
• Problems with the service you receive from Member Service. 
• Problems with how long you have to wait on the phone, in the waiting room, or in the exam room.
• Problems with how long you have to wait in a network pharmacy.
• Problems getting appointments when you need them, or waiting too long for them.
• Waiting too long for prescriptions to be filled.
• Rude behavior by doctors, nurses, receptionists, network pharmacists or other staff.
• Cleanliness or condition of doctor’s offices, clinics, network pharmacies, or hospitals.
• You believe our notices and other written materials are hard to understand.

If you have one of these types of problems and want to make a complaint, it is called “filing a grievance.”

Filing a grievance with our plan

If you have a grievance, please talk to your Team or call customer service at 866-992-6600. We will try to resolve your grievance over the phone. If you ask for a written response, we will respond in writing to you.

We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your grievance. We may extend the time frame by up to 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. In certain cases, you have the right to ask for a “fast grievance,” meaning your grievance will be resolved within 24 hours.  You have the right to request a fast grievance from the Plan or the Department of Health and Family Services if we extend the timeframe for making an organization determination or reconsideration; or we refuse to grant a request for an organization determination or reconsideration; or we refuse to honor your request for a “fast” or “expedited” appeal.

For quality of care problems, you may also complain to MetaStar

You may complain about the quality of care you received, including care during a hospital stay. You may complain to us using the grievance process or to an independent review organization called MetaStar. If you file with MetaStar, we must help them resolve the grievance

You may contact MetaStar at:

MetaStar, Inc
2902 Landmark Place
Madison, WI 53713
(608) 274-1940
Toll Free Number: (800) 362-2320

What to do if you have complaints about your Medicare Part D prescription drug benefits

We encourage you to let us know right away if you have questions, concerns, or problems related to your Medicare Part D prescription drug coverage. Please call Member Services at the number at (866) 992-6600. Please note that this section addresses complaints about your Medicare Part D prescription drug benefits.

This section gives the rules for making complaints in different types of situations. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled or penalized in any way if you make a complaint.

A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint.

A grievance is any complaint other than one involves a coverage determination. You would file a grievance if you have any type of problem with us or one of our network pharmacies that does not relate to coverage for a Medicare Part D prescription drug.

A coverage determination is the first decision we make about covering the drug you are requesting.  If your doctor or pharmacist tells you that a certain Medicare Part D prescription drug is not covered, you may contact us if you want to request a coverage determination.

An appeal is any of the procedures that deal with the review of an unfavorable coverage determination.  You cannot request an appeal if we have not issued a coverage determination.  If we issue an unfavorable coverage determination, you may file an appeal called a "redetermination" if you want us to reconsider and change our decision.  If our redetermination decision is unfavorable, you have additional appeal rights. For more information about appeals, see the appeal process.