Grievances and Appeals
Your health and satisfaction are important to us. When you have a problem or concern, please call ArchCare Advantage Customer Service Department first at 1‑800‑373‑3177 (TTY/TDD: 1‑800‑662‑1220), seven days a week, 8 a.m. to 8 p.m. Our customer service staff will work with you to try to find a satisfactory solution to your problem.
However, if for some reason your issue isn’t settled to your satisfaction, there are formal steps you can take. You have rights as a member of our plan and as someone who is receiving Medicare. We honor your rights, take your problems and concerns seriously, and treat you with fairness and respect.
For more information, see the section titled “Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)” in the Evidence of Coverage.
There are two types of formal processes for handling problems and concerns:
- If you disagree with a service/coverage determination we have made, you need to use the process for filing appeals.
- For other types of problems, you need to use the process for making complaints, which are also called grievances.
Both of these processes are approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures and deadlines that must be followed by us and by you.
Making an Appeal
If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking the plan to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision to check if we were following all of the rules properly. Your appeal is handled by different reviewers than those who make the original decision. When we have completed the review, we give you our decision.
If you wish, you can appoint someone to act for you and communicate with us on your behalf about your benefits and your appeal. This can be a relative, friend, a healthcare professional or lawyer, or any other person or organization you want to represent you. To do so, you must complete, sign and send us an Appointment of Representative form that gives that person or organization permission to speak with us and make decisions for you.
If you need help filling out the form or want to learn more about appointing a representative, you can call us at 1‑800‑373‑3177 (TTY/TDD: 1‑800‑662‑1220), seven days a week, 8 a.m. to 8 p.m.
How to Make an Appeal
To start your appeal, you, your doctor or your representative must contact our plan. If you are asking for a standard appeal, make your appeal by submitting a written request. If you are asking for a “fast appeal,” you may make your appeal in writing or by calling us at the number listed below. You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you of our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.
If your health requires it, ask for a “fast appeal.” If we are using the fast deadlines, we will give you our answer within 72 hours after we receive your Part C (Medical) or Part D (prescription drug) appeal. We will give you our answer sooner if your health requires it.
If we are using the standard deadlines, we will give you our answer within seven calendar days after we receive your Part D (prescription drug) appeal or within 30 calendar days after we receive your Part C (Medical) appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for “fast appeal.” In some cases, such as when additional information is needed and it is in your best interest to extend the time frame of our response, we may extend the time up to 14 days. If we extend the time, you will receive notification from the plan.
There are three ways to file an appeal for Part C medical services:
- By phone: 1‑800‑373‑3177 (TTY/TDD 1‑800‑662‑1220), seven days a week, 8 a.m. to 8 p.m.
- By fax: 1‑212‑524‑5163
- By mail: Appeals & Grievances Department, 33 Irving Place, 11th Floor, New York, NY 10003.
Payment appeals are accepted only in writing.
There are four ways to file an appeal for Part D (prescription drugs) determination:
- By phone: To request a fast appeal, call 1‑855‑344‑0930 (TTY/TDD: 711) 24 hours a day, seven days a week
- By mail: If you wish to file a standard appeal, you must send written request within sixty (60) days from the date of the notice of coverage determination to: CVS Caremark Part D Services, MC109, PO Box 52066, Phoenix, AZ 85072-2066.
- By fax: Fax the completed Redetermination Request Form within sixty (60) days from the date of the notice of coverage determination to 1‑855‑633‑7673.
- Online: Within sixty (60) days from the date of the notice of coverage determination, you may submit a Redetermination Request Form online here: https://cdrd.cvscaremarkmyd.com/CoverageReDetermination.aspx?ClientID=13
You can download the Redetermination Request Form to use for your appeal:
If we say no to your appeal, you can then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed.
To make a Level 2 Appeal, you must contact the Independent Review Organization and ask for a review of your case. If we say no to your Level 1 Appeal, the written notice we send you will include instructions on how to make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow and how to reach the review organization.
The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us, and it is not a government agency. This organization is a company chosen by Medicare to review our decisions about your benefits with us.
What if the review organization says no to your appeal? If this organization says no to your appeal, it means the organization agrees with our decision not to approve your request. To continue and make another appeal at Level 3, the dollar value of the drug or medical coverage you are requesting must meet a minimum amount. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal, and the decision at Level 2 is final. The notice you get from the Independent Review Organization will tell you the dollar value that must be in dispute to continue with the appeals process. If the dollar value of the coverage you are requesting meets the requirement, you choose whether you want to take your appeal further. There are three additional levels in the appeals process after Level 2, for a total of five levels of appeal. If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. If you decide to make a third appeal, the details on how to do this are in the written notice you got after your second appeal. The Level 3 Appeal is handled by an administrative law judge. Chapter 9 of the Evidence of Coverage – Determinations has more information about Levels 3, 4 and 5 of the appeals process.
The formal name for making a complaint is “filing a grievance.” The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times and the customer service you receive. You can file a grievance or someone you authorize can do so on your behalf.
If you have any of these problems, you may file a grievance:
- You are unhappy with the quality of the care you received.
- You believe that someone did not respect your right to privacy or shared information you feel should be confidential.
- You were kept waiting too long.
- You are unhappy with the cleanliness or condition of a hospital, doctor’s office or pharmacy.
You may submit feedback about ArchCare Advantage directly to Medicare or the NYS Office of Long-Term Care Ombudsman Program using the links below.