If you have a complaint, you or your representative may call the phone number for Part C Grievances (for complaints about Part C medical care or services) or Part D Grievances (for complaints about Part D drugs) in Section 8. We will try to resolve your complaint over the phone. If you ask for a written response, file a written grievance, or your complaint is related to quality of care, 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 our written (or formal) grievance procedure. Your grievance will be referred to our Grievance & Appeals department. A Grievance & Appeals coordinator will acknowledge your grievance in writing, investigate your case and send you a response in writing.

The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.

In certain cases, you have the right to ask for a “fast grievance,” meaning we will answer your grievance within 24 hours. We discuss situations where you may request a fast grievance in Section 5 of your Evidence of Coverage.

You may complain about the quality of care received under Medicare, including care during a hospital stay. You may complain to us using the grievance process, to the Quality Improvement Organization (QIO), or both. If you file with the QIO, we must help the QIO resolve the complaint. See Section 8 of your Evidence of Coverage for more information about the QIO and for the name and phone number of the QIO in your state.

You may file an Appeal (also called redetermination) when you want us to reconsider and change a Coverage Determination that we have made , i.e., you want to appeal a decision we made about covering a Part D prescription drug or your cost-sharing for a drug. Appeals are handled as quickly as the member's case requires, based on their health status, but no later than seven (7) calendar days after receiving the request for reconsideration. An Expedited (fast) Appeal will be handled within seventy-two (72) hours.

You, your legal or appointed representative, or Provider may file an appeal on your behalf.

CALL 1-888-980-8764 (TTY/TDDTTY 1-800-498-5428). Calls to this number are free. FAX 1-714-825-3798 or (877)239-4565 WRITE :Part D Appeals, Mail Stop CA106-0286, 3515 Harbor Blvd , Costa Mesa, CA 92626.

For information about Part D appeals, see Section 5 of your Evidence of Coverage.

If upon appeal, we uphold our original decision, in whole or part, you may request an independent review entity (IRE) to make an independent decision. The IRE has a contract with CMS to review these member appeals. The IRE will make a decision and notify you and us of its decision. If the IRE upholds PUP's decision, you will be informed of further rights to administrative and judicial review.

Grievance Form

Appointment of Representative Form - *An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal. If you would like to appoint a representative please reference the CMS Appointment of Representation form (Form CMS-1696). You and your appointed representative must complete this form and, send it to us at your request or grievance.

If you or your physician have questions about the grievance, coverage determination, or appeals processes or would like to inquire about the status of a coverage determination or appeal request, please contact PUP’s Member Services Department at 1-866-571-0673 (TTY/TDD 1-800-955-8771), 7 days per week, 8:00 AM - 8:00 PM.

For further information about PUPs Grievances, Coverage Determination, and Appeals Processes, please refer to your Evidence of Coverage. To view, click here, choose the Plan you are enrolled in, and then click on Evidence of Coverage.

When you ask for it, the government requires PUP, Inc. to provide you with reports that describe what happened to formal complaints that our plan received from our Medicare members. There are two types of formal complaints: Appeals and Grievances. Medicare members have a right to file an appeal or grievance with their Medicare health plans. An appeal is a formal complaint about Physicians United Plan’s decision not to pay for, not to provide, or to stop an item or service that a Medicare member believes s/he needs.

Each Medicare health plan will have different numbers of appeals and quality of care grievances, and these numbers can mean different things. For example, a Medicare health plan might have a small number of appeals and quality of care grievances because the plan talks with members about their concerns and agrees to find solutions. You may contact the plan and ask for a summary report of the number of grievances and appeals received and what happened to those complaints over a specific period of time.

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