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Member Grievance and Appeal Information 2021

Click here for 2020 Member Grievance and Appeal Information


If you do not agree with a decision made by Medica HealthCare Plans you can submit an appeal that is a formal way of asking us to review and change a coverage decision we have made.

You can make a complaint about us or one of our network pharmacies, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes.

You can download the form below and follow the steps listed to file your Grievance or Appeal.

  1. Download the Member Grievance and Appeal Request Form
  2. Include copies of documents that help support the appeal.
  3. Mail or fax completed form and documentation to:

 

Grievance and Appeals for Medical Care - Part C

  • Medica HealthCare Plans MedicareMax (HMO)
Mail

Medica HealthCare
Appeals and Grievance Department
P.O. Box 6106, MS CA124-0157, Cypress, CA 90630-0016

Fax

Standard Appeal: 1-888-517-7113
Expedited Appeal: 1-866-373-1081

Grievance and Appeals for Medical Care - Part C

  •  Medica HealthCare Plans MedicareMax Plus (HMO D-SNP)
Mail

Medica HealthCare
Appeals and Grievance Department
PO Box 6106, MS CA 124-0187, Cypress, CA 90630-0016

Fax

Expedited Appeal: 1-866-373-1081

Grievance and Appeals for Prescription Drugs for all plans - Part D

Mail

Medica HealthCare
Part D Appeals and Grievance Department
P.O. Box 6106, MS CA124-0197, Cypress, CA 90630-0016

Fax

Standard Appeal: 1-866-308-6294
Expedited Appeal: 1-866-308-6296

As a member of our plan, you have the right to get several kind of information from us. This includes information about the number of appeals made by members and the plan's performance rating including how it has been rated by plan members and how it compares to other Medicare Advantage health plans. To file a complaint directly to CMS, click on this link: https://www.medicare.gov/MedicareComplaintForm/home.aspx

For detailed information on the process of filing a grievance or appeal and obtaining a coverage determination, refer to Chapter 9 of your Evidence of Coverage.