If you have prescription drug coverage please refer to chapter nine of your plan's evidence of coverage (EOC) for more information regarding grievance, determination and appeals processes. If you do not have prescription drug coverage please refer to chapter seven of your plan's evidence of coverage (EOC) for more information regarding grievance, determination and appeals processes.

You may contact customer service with any questions or concerns including how to obtain information regarding the aggregate number of grievances, appeals, and exceptions filed with Providence Medicare Advantage Plans.

An organization determination is also called a "coverage decision." An organization determination is the initial decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We are making an organization determination anytime we decide what is covered for you and how much we will pay. If you are having problems getting medical care, a service you requested, or payment (including the amount you have already paid) for medical care or services you have already received, then you can resolve the problem through an organization determination. If your health requires a quick response, you should ask us to make a "fast decision." If we say no, you have the right to ask us to reconsider - and perhaps change - this decision by making an appeal.

To check status or request an organization determination you, your doctor, or your representative may:

Call:

503-574-8000 or toll free 1-800-603-2340 TTY: 711

Fax:

503-574-8608

Write:

Providence Medicare Advantage Plans
PO Box 4327
Portland, OR 97208-4327

If we make a coverage decision and you are not satisfied with our decision or part of our decision, you or your representative can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. If your health requires a quick response, you must ask for a "fast appeal."

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the benefits properly. When we have completed the review, we will give you our decision in writing.

If we say no to all or part of your Part C Level 1 Appeal, your appeal will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our Plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal. If we say no to all or part of your Part D Level 1 Appeal, you must ask the independent organization yourself for a Level 2 Appeal. These additional levels are explained in your member handbook/evidence of coverage.

To file an appeal, you or your representative may:

Call:

503-574-8000 or toll free 1-800-603-2340 TTY: 711

Fax:

503-574-8757 or 1-800-396-4778

Write:

Providence Medicare Advantage Plans
Attn: Appeals and Grievances Department
PO Box 4158
Portland, OR 97208-4158

A grievance is any complaint, other than one that involves a request for an initial determination or an appeal as described in the determinations and appeals section of your member handbook/evidence of coverage.

If you have a complaint about quality of care, waiting times, or the customer service you receive, you or your representative may call 503-574-8000 or 1-800-603-2340 (TTY line at 711). We will try to resolve your complaint over the phone. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the Providence Medicare Advantage Plans Grievance Procedure.

To use the formal grievance procedure, you may submit your written grievance to the Providence Appeals and Grievance Department. If you file a written grievance, or your complaint is related to quality of care, we will respond in writing to you.

You may request an expedited grievance if you disagree with our decision to:

• Not grant you an expedited appeal.
• Not grant you an expedited determination.
• Extend the standard review period of an initial decision or appeal.

We will promptly acknowledge that we received your expedited or "fast grievance" within 24 hours. A resolution to your grievance will be accomplished in the timeliest manner and in no more than 72 hours from the time of our receipt. The grievance must be submitted within 60 days of the event or incident.

To file a grievance, you or your representative may:

Call:

503-574-8000 or toll free 1-800-603-2340 TTY: 711

Fax:

503-574-8757 or 1-800-396-4778

Write:

Providence Medicare Advantage Plans
Attn: Appeals and Grievances Department
PO Box 4158
Portland, OR 97208-4158

You may complain about the quality of care you received, 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. Please refer to Chapter 2, Section 4, of your member handbook/evidence of coverage for additional information about the Quality Improvement Organization in your state.

The Centers for Medicare & Medicaid Services (CMS) has changed the national Quality Improvement Organization (QIO) Program, separating medical case review from quality improvement work. Beginning August 1, 2014, QIO work will be carried out in each state under two types of regional contracts:

Medical case review will be performed by Beneficiary and Family Centered Care QIOs (BFCC-QIOs).

KEPRO is the point of contact for Member Appeals for the states of Oregon and Washington.

KEPRO

Phone:

813-280-8256 (local) or 1-888-305-6759 (toll-free)

TTY: 1-855-843-4776

Local hours are 9 a.m. to 5 p.m. (Pacific Time) Monday to Friday and 11 a.m. to 3 p.m. (Pacific Time) weekends and holidays. A message can also be left at 1-888-305-6759 24 hours a day, seven days a week.

Mailing Address:

KEPRO
5700 Lombardo Center Dr., Suite 100
Seven Hills, OH 44131

Website:

https://www.keproqio.com

If you have complaints or concerns about Providence Medicare Advantage Plans and would like to contact Medicare directly please complete the CMS complaint form.

The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances and information requests.

You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call customer service. If you are requesting Part C medical care or services, this statement must be sent to us at the address or fax number listed under "Part C Organization Determinations."

If you would prefer that someone else act on your behalf, please complete the CMS appointment of representative form (PDF), sign it and return it to us.

Call - if it is a fast appeal:

503-574-8000 or toll free 1-800-603-2340(TTY: 711), M-Sun, 8 a.m. to 8 p.m.

Fax:

503-574-8757 or 1-800-396-4778

Write:

Providence Medicare Advantage Plans
Attn: Appeals and Grievances Department
PO Box 4158
Portland, OR 97208-4158

In person:

Providence Medicare Advantage Plans
Attn: Appeals and Grievance Department
3601 SW Murray Blvd., Suite 10
Beaverton, OR 97005

Non-appeal payment determinations require a CMS appointment of representative form (PDF) if someone other than the enrollee is submitting a member reimbursement on the enrollee's behalf.

Write:

Providence Medicare Advantage Plans
Attn: Medicare Advantage Claims
PO Box 3125
Portland, OR 97208-3125

Member authorization forms

• Allow Providence Medicare Advantage Plans to share your protected health information with a third party (PDF)