Grievances

A grievance is different from a request for an organization determination, or a request for an appeal because grievances do not involve problems related to approval or payment for care or Part D benefits, hospital care ending too soon, and Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending too soon.

A fast grievance: is any complaint regarding the Medicare Advantage Organization’s decision to extend a timeframe to make an organization determination or reconsideration, or refusal to grant a request for a fast organization determination or reconsideration.

For problems regarding coverage or payment for care, being discharged from the hospital too soon, and coverage for SNF, HHA, or CORF services ending too soon, you must follow the rules outlined in Sections 9 and/or 10 of your Evidence of Coverage.

If you have a problem with Positive Healthcare Partner’s failure to cover or pay for a Part D prescription drug, you must follow the rules outlined in Section 12 of your Evidence of Coverage.

Filing a Grievance with Positive Healthcare Partners

If you have a grievance, please call (888) 456-4715 or send your grievance in writing to:

Positive Healthcare Partners
Attn: Member Services
4101 Ravenswood Ave., Suite 325
Fort Lauderdale, FL 33312

We will try to resolve your complaint over the phone. If you ask for a written response, we will respond to you in writing. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this a member grievance. 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.

Appeals

If we deny any part of your request for a service or payment of a service (including prescription drugs) you may ask us to reconsider our decision. This is called an “Appeal” or a “Request for Reconsideration."

Please call us at (888) 456-4715 if you need help in filing your appeal. We give the request to different people than those who made the organization determination. This helps ensure that we will give your request a fresh look. If your appeal concerns a decision we made about a service you asked for, then you and/or your doctor will first need to decide whether you need a fast appeal. The procedures for resolution of standard or fast appeals are the same as those described for standard or fast initial decisions.

Obtaining Information to Support Your Appeal

We must gather all the information we need to make a decision about your appeal. If we need your assistance in gathering this information, we will contact you. You have the right to obtain and include additional information as part of your appeal. For example, you may already have documents related to your request, or you may want to obtain your doctor’s records or opinion to help support your request. You may need to give the doctor a written request to obtain information

You may give us additional information to support your appeal by calling (888) 456-4715 or writing to:

Positive Healthcare Partners
Attn: Member Services
4101 Ravenswood Ave., Suite 325
Fort Lauderdale, FL 33312

You also have the right to request a copy of the information we have regarding your appeal. You may call us at (888) 456-4715 or write us at:

Positive Healthcare Partners
Attn: Member Services
4101 Ravenswood Ave., Suite 325
Fort Lauderdale, FL 33312

How Do You File Your Appeal of the Organization Determination?

The rules about who may file an appeal are the same as the rules about who may ask for an organization determination. Follow the instructions under the “Organization Determination” section in your Evidence of Coverage. However, providers who do not have a contract with PHP must sign a “waiver of payment” statement that says that they will not ask you to pay for the medical service under review, regardless of the outcome of the appeal.

How Soon Must You File Your Appeal?

You must file your appeal within 60 days after we notify you of our decision. We may give you more time if you have a good reason for missing the deadline. To file your appeal, you may call us at
(888) 456-4715 or write us at:

Positive Healthcare Partners
Attn: Member Services
4101 Ravenswood Ave., Suite 325
Fort Lauderdale, FL 33312

What If You Want a Fast Appeal?

The rules about asking for a fast are the same as those for a fast coverage determination.

How Soon Must We Decide on Your Appeal?

For a decision about payment for care you already received:

After we receive your appeal, we have 60 days to make a decision. If we do not decide within 60 days, your appeal automatically goes to Appeal Level 2.

For a standard decision about medical care:

After we receive your appeal, we have up to 30 days to make a decision, but will make it sooner if your health condition requires. However, if you request it, or if we find that some information is missing which can help you, we can take up to 14 more days to make our decision. If we do not tell you our decision within 30 days (or by the end of the extended time period), your request will automatically go to Appeal Level 2.

For a fast decision about medical care:

After we receive your appeal, we have up to 72 hours to make a decision, but will make it sooner if your health requires. However, if you request it, or if we find that some information is missing which can help you, we can take up to 14 more days to make our decision. If we do not tell you our decision within 72 hours (or by the end of the extended time period), your request will automatically go to Appeal Level 2.