A grievance is an expression of dissatisfaction with any aspect of the operations, activities, or behavior of a plan or its delegated entity in the provision of health care or prescription drug services or benefits, regardless of whether remedial action is requested.
Grievances about quality – You are unhappy with the quality of care, such as the care you received in the hospital.
Grievances about privacy – You think that someone did not respect your right to privacy, or shared information about you that is confidential.
Grievances about poor customer service – A health care provider or staff was rude or disrespectful to you.
Grievances about physical accessibility – You cannot physically access the health care services and facilities in a provider’s office.
Grievances about waiting times – You are having trouble getting an appointment, or waiting too long to get it.
Grievances about cleanliness – You think the clinic, hospital or provider’s office is not clean.
Grievances about communications from us – You think the written information we sent you is too difficult to understand.
File a Grievance
You can also send your grievance (complaint) to Medicare.
Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. The call is free. Your grievance will be sent to the Medicare and Medicaid team overseeing the PHP Care Complete FIDA-IDD Plan.
Medicare Complaint Form
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Time Period for Grievance Filing:
- Standard grievance notifications will be delivered no later than 30 days from receipt (plus a 14-day extension, if applicable).
- Expedited grievance notifications will be resolved within 24 hours.
Coverage Determinations &Appeals
The process for asking for coverage determinations and making appeals deals with problems related to your benefits and coverage. It also includes problems with payment.
What is a coverage determination?
A coverage determination is an initial decision your Interdisciplinary Team (IDT), PHP Care Complete FIDA-IDD Plan, or an authorized specialist makes about your benefits and coverage or about the amount PHP Care Complete FIDA-IDD Plan will pay for your medical services, items, or drugs. Your IDT, PHP Care Complete FIDA-IDD Plan, or your authorized specialist is making a coverage determination whenever it decides what is covered for you and how much PHP Care Complete FIDA-IDD Plan will pay. Authorized specialists include dentists, optometrists, ophthalmologists, and audiologists.
The PHP enrollee, enrollee’s representative, or the provider on behalf of the enrollee, has the right to request a pre-service organization determination (prior authorization).
Coverage Determination Time Period
- Members who contact the call center requesting coverage determination (including exceptions requests) will receive the following turnaround:
- 24 hours for expedited grievances
- 72 hours for standard requests
What is an appeal?
An appeal is a formal way of asking us to review a decision made by your IDT, PHP Care Complete FIDA-IDD Plan, or authorized specialist and change it if you think a mistake was made. For example, your IDT, PHP Care Complete FIDA-IDD Plan, or authorized specialist might decide that a service, item, or drug that you want is not covered. If you or your provider disagree with that decision, you can appeal.
Note: You are a member of your IDT. You can appeal even if you participated in the discussions that led to the coverage determination that you wish to appeal.
Who can I call for help asking for coverage determinations or making an appeal?
You can ask any of these people for help:
- You can call us at Participant Services at 1-855-747-5483 or TTY/TDD: 711.
- You can call your Clinical Team Leader. Their phone number is on the front of your ID Card.
- The State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by PHP Care Complete FIDA-IDD Plan. The Participant Ombudsman may be reached toll-free at 1-844-614-8800 (TTY users call 711) or online at icannys.org.
- Call the Health Insurance Information, Counseling, and Assistance Program (HIICAP) for free help. The HIICAP is an independent organization. It is not connected with this plan. The phone number is 1-800-701-0501.
- Talk to your provider. Your provider can ask for a coverage determination or appeal on your behalf.
- Talk to a friend or family member and ask him or her to act for you. You can name another person to act for you as your “representative” to ask for a coverage determination or make an appeal.
Please go to Chapter 9 of your Participant Hand book found in your 2022 Member Materials, or call Participant Services at 1-855-747-5483 or TTY/TDD: 711 for more information on appeals. If you would like to learn the number of grievances, appeals and exceptions that have been filed with PHP Care Complete FIDA-IDD Plan, please call Participant Services at 1-855-747-5483 or TTY/TDD: 711.