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Appeals and Grievances

What is an appeal?

An appeal is a special kind of complaint you can make if KelseyCare Advantage refuses to cover something you think should be covered. If you disagree with the plan’s initial decision (organization determination), you, your representative, or your treating physician can request an appeal, but you must make your request within 60 days from the date of the organization determination. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

Requesting an appeal means asking us to reconsider—and possibly change—the decision we made. An appeal to the plan about an organization determination is called a plan “reconsideration.” Please refer to your Evidence of Coverage that discusses the five levels of appeals. When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were being fair and following all the rules when we said no to your request. We may contact you or your doctor to get more information.

Who can file an appeal?

You, your representative, or your treating physician can ask for a standard or fast appeal. You will get a fast decision if we determine or your physician tells us that your life or health may be at risk by waiting for a standard decision. The decision request deadlines are as follows:

Type Part C Part D
Standard Pre-Service or Benefit 30 days 7 days
Expedited Pre-Service, Benefit or Part B Drug 72 hours 72 hours
Standard Part B Drug 7 days N/A
Payment 60 days 14 days

How do you file an appeal?

For standard appeal requests, you or your representative, or your treating physician must make your request to us in writing. Your written reconsideration request should include:

  • Your name, address, and your member ID number.
  • The items or services for which you’re asking for a reconsideration and the dates of service.
  • Your signature.
  • You should also include any other information that may help your case.
  • A “fast” or expedited appeal is accepted by us in writing, in person, or over the telephone.

What is a grievance (complaint)?

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. Here are examples of the kinds of problems handled by the complaint process.

  • Do you believe that someone did not respect your privacy or shared information about you that you feel should be confidential?
  • Has someone been rude or disrespectful to you?
  • Do you feel that you were waiting too long on the phone or when getting medical care?
  • Do you believe we have not given you a notice that we are required to give?
  • If you have asked us to give you a “fast response” for an organizational determination or an appeal, and we have said we will not, you can make a complaint.
  • If you believe our plan is not meeting deadlines for giving you an organizational determination or an answer to an appeal you have made, you can make a complaint.

You must file a grievance within 60 days from the date of the event that led to the complaint. Grievances are reviewed on an individual basis and we will resolve the grievance as quickly as your health status requires. If you call us with a complaint, we may be able to give you an answer on the same phone call. 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. Expedited or fast grievances will be responded to within 24 hours if the grievance is related the plan’s refusal to make a fast coverage organization determination or reconsideration and you haven’t received the medical care yet. We will address other grievance requests within 30 days after receiving your complaint. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days to answer your complaint.

How to contact us when you are making an appeal or a complaint:

1-866-535-8343

Hours of Operation: From October 1 through March 31, hours are 8 a.m. to 8 p.m., seven days a week. During this time period on Thanksgiving Day and Christmas Day, calls are handled by our voicemail system. From April 1 through September 30, hours are 8 a.m. to 8 p.m., Monday through Friday. During this time period on Saturdays, Sundays and federal holidays, calls are handled by our voicemail system. We will return calls the next business day.

Contact us by:
Phone 1-866-535-8343

TTY: 711

This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.

FAX: 1-713-442-9536

Mail KelseyCare Advantage
Attn: Grievance and Appeals
P.O. Box 841569
Pearland, TX 77584-9832

For information about the total number of grievances, appeals and exceptions filed with KelseyCare Advantage, please contact KelseyCare Advantage using the phone numbers listed above.

You can submit a complaint directly to Medicare. To submit an online complaint to Medicare go to https://www.medicare.gov/MedicareComplaintForm/home.aspx. You can also call Medicare at 1-800-MEDICARE (1-800-633-4227),

2020 Plans 

PDF

Rx Plan

 

Rx+Choice Plan

 

Rx Select Plan

 

Essential Plan

 

Essential+Choice Plan

 

Essential Select Plan

 

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