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
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 Express Scripts Customer Care line at (877) 657-2498 or TTY/TDD (800) 899-2114. 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 Express Scripts. Written requests should be delivered to Grievance Resolution Team, P.O. Box 3610 Dublin, OH 43016-0307. 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. However, you will receive a response to a grievance within 24 hours if: The grievance involves a refusal by the Part D plan sponsor to grant an enrollee’s request for expedited determination, and the enrollee has not yet purchased or received the drug that is in dispute.
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)
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