Drug Coverage Determinations

What is a grievance? 
A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with Central Health Medicare Plan or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.

How to file a grievance?
Chapter 9 of the Evidence of Coverage explains how to file a grievance. A grievance is different from a request for a coverage determination because it usually will not involve coverage or payment for Part D prescription drug benefits (concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process.

  • You feel that you are being encouraged to leave (disenroll from) Central Health Medicare Plan.

  • Problems with the Member Service you receive.

  • Problems with how long you have to spend waiting on the phone or in the pharmacy.

  • Disrespectful or rude behavior by pharmacists or other staff.

  • Cleanliness or condition of pharmacy.

  • If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination.

  • You believe our notices and other written materials are difficult to understand.

  • Failure to give you a decision within the required timeframe.

  • Failure to forward your case to the independent review entity if we do not give you a decision within the required timeframe.

  • Failure by the Plan to provide required notices.

  • Failure to provide required notices that comply with CMS standards.

In certain cases, you have the right to ask for a “fast grievance,” meaning your grievance will be decided within 24 hours. We discuss these fast-track grievances in more detail below.

If you have a grievance, we encourage you to first call Member Services at the number (866) 314-2427 or TTY/TDD (888) 205-7671. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, 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. We call this the Central Health Medicare Plan Appeals and Grievance process. You may file a grievance by submitting an oral or written request to the Plan. Written requests should be delivered to Central Health Medicare Plan, Member Services Department, 1540 Bridgegate Drive, Diamond Bar, CA 91765 or faxed to (626) 388-2361. The Member Services staff will assist you in documenting your issue on a Grievance Form. Grievances will be processed by the Member Services Appeals / Grievance (“AG”) Coordinator. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. The time frame for completion of requests for expedited grievances is 72 hours. The grievance shall be completed expeditiously and your medical condition shall be considered when determining the response time. A written statement will be sent on the disposition or pending status of the expedited grievance no later than three calendar days from receipt of the grievance. You will also be notified by telephone of the status.

For quality of care complaints, you may also complain to Health Services Advisory Group, Inc. (HSAG) the Quality Improvement Organization (QIO)

Complaints concerning the quality of care received under Medicare may be acted upon by the plan sponsor under the grievance process, by an independent organization called Health Services Advisory Group, Inc. (HSAG), or by both. For example, if an enrollee believes his/her pharmacist provided the incorrect dose of a prescription, the enrollee may file a complaint with HSAG in addition to or in lieu of a complaint filed under the plan sponsor's grievance process. For any complaint filed with HSAG, the plan sponsor must cooperate with the QIO in resolving the complaint. For more details on filing a complaint with HSAG, refer to the Evidence Of Coverage (EOC) booklet.

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