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 Medica HealthCare Plans, 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.
Please contact the Member Services Department for more information on how to file a grievance with Medica Healthcare Plans. You can also file a written grievance at:
PO Box 6106,
MS CA124-0197
Cypress, CA 90630-0016
Fax: 1-866-308-6294
What is a coverage determination?
Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request. You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.
Please contact the Member Services Department for more information on how to request a coverage determination by Medica Healthcare Plans. You can also request a coverage determination in writing or by fax at:
PO Box 29675
Hot Springs, AR 71903-9675
Fax: 1-800-517-6294
What is an organization determination?
An organization determination is a decision made by the health plan about whether items or services are covered or how much you have to pay for covered items or services. The Medicare Advantage organization's network provider or facility has also made an organization determination when it provides you with an item or service, or refers you to an out-of-network provider for an item or service. You must contact us if you would like to request an organization determination. You cannot request an appeal if we have not issued an organization determination.
Please contact the Member Services Department for more information on how to request a coverage of organization determination by Medica Healthcare Plans. You can also request a coverage of organization determination in writing or by fax at:
PO Box 29675
Hot Springs, AR 71903-9675
Fax: 1-800-517-6294
What is an appeal?
An appeal is any of the procedures that deal with the review of an unfavorable coverage determination or organization determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug. You may also file an appeal if you want us to reconsider and change a decision we have made about whether items or services are covered or how much you have to pay for covered items or services.
Please contact the Member Services Department for more information on how to file an appeal with Medica Healthcare Plans. You can file your appeal in writing or by fax at:
Part CMember Part C Appeal or Written Grievance:
PO Box 6106
MS CA 124-0157
Cypress, CA 90630
Standard, (888) 517-7113
Expedited, (866) 373-1081
Part D
Appeal, coverage Determination or Written Grievance: (member and provider):
Part D Appeals and Grievance Department
ATTN: CA-124-0197
PO Box 6106
Cypress, CA 90630-9948
Standard Fax# 866-308-6294
Expedited Fax# 866-308-6296
Appeals & Grievance Information
If you would like information on the aggregate number of appeals, grievances, and exceptions filed with Medica Healthcare Plans, please contact the Member Services Department. To file a complaint directly to CMS. link https://www.medicare.gov/MedicareComplaintForm/home.aspx
