Grievances and appeals

You have the right to file a grievance, or complaint, about us or one of our plan providers for matters other than payment or coverage disputes.

Examples of grievances include:

• The customer service you receive
• Waiting too long on the phone, waiting room, in the exam room or when getting a prescription
• The length of time required to fill a prescription or the accuracy of filling a prescription
• The quality of care you received from a provider or facility

Grievances must be filed within 60 days of the event or incident. You may send a complaint to us in writing or by calling Customer Service. If you wish to appoint someone to act on your behalf, you must complete an appointment of representative form (PDF) and send it to us with your grievance form (PDF).

We must notify you of our decision about your grievance within 30 calendar days after receiving your grievance.

Contact information
Regence
ATTN: Medicare Advantage/Medicare Part D Appeals and Grievances
P.O. Box 1827 Medford, OR 97501

Oral coverage decision requests
1 (855) 522-8896

To request or check the status of a redetermination (appeal): 1 (866) 749-0355

Fax numbers
Appeals and grievances: 1 (888) 309-8784
Prescription coverage decisions: 1 (888) 335-3016

Coverage decisions
A coverage decision is a decision we make about what we’ll cover or the amount we’ll pay for your medical services or prescription drugs.

Examples of coverage decisions include:

• Formulary exceptions *
• Copayment tiering exceptions *
• Requests to find out if a medical service or procedure is covered

We respond to pharmacy requests within 72 hours for standard requests and 24 hours for expedited requests. * * We respond to medical coverage requests within 14 days for standard requests and 72 hours for expedited requests. Coverage decision requests can be submitted by you or your prescribing physician by calling us or faxing your request. If you wish to appoint someone to act on your behalf, you must complete an appointment of representative form and send it to us with your prescription coverage determination form.

* If you are asking for a formulary or tiering exception, your prescribing physician must provide a statement to support your request. You cannot ask for a tiering exception for a drug in our Specialty Tier. In addition, you cannot obtain a brand-name drug for the copayment that applies to the generic drug.

* * If you, or your prescribing physician, believe that waiting for a standard decision (which will be provided within 72 hours) could seriously harm your life, health or ability to regain maximum function, you can ask for an expedited decision. If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing or through a phone call to us) that he or she agrees that waiting 72 hours could seriously harm your life, health or ability to regain maximum function, we will give you a decision within 24 hours. If you do not obtain your physician's support, we will decide if your health condition requires a fast decision.

Appeals

You have the right to appeal, or request an independent review of, any action we take or decision we make about your coverage, benefits or services. You can submit your appeal online, by email, by fax, by mail, or you can call using the number on the back of your member ID card. There are several levels of appeal, including internal and external appeal levels, which you may follow. Contact us as soon as possible because time limits apply.