Grievances

• Problems with the service you receive from Member Services.
• If you feel that you are being encouraged to disenroll from the Plan.
• If you disagree with our decision not to give you a “fast” decision or a “fast” appeal.
• We don’t give you a decision within the required time frame.
• We don’t give you required notices.
• You believe our notices and other written materials are hard to understand.
• Problems with the quality of the medical care or services you receive, including quality of care during a hospital stay.
• Problems with how long you must wait on the phone, in the waiting room, or in the exam room.
• Problems getting appointments when you need them, or waiting too long for them.
• Rude behavior by doctors, nurses, receptionists, or another staff.
• Cleanliness or condition of doctor’s offices, clinics, or hospitals.

If you have one of these types of problems and want to make a complaint, it is called “filing a grievance”.

You or someone you name may file a grievance. The person you name would be your “representative”. 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. You must complete the Appointment of Representative form.
For more information, call Member Services.

If you have a complaint, you or your representative may call Member Services. 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 Health Administration Grievance Process. Please tell the Customer Representative that you want to file a grievance. In return, the Customer Representative will forward your grievance request for processing. You may file your grievance verbally or in writing. If you want to write to us rather than file a verbal grievance, you may address your correspondence to the following address:

MMM of Florida
Appeals and Grievances
P.O. Box 260430
Miami, FL  33126

If your complaint involves a refusal to grant a request for an expedited coverage determination or an expedited redetermination and you have not purchased or received the drug in dispute, we must respond to your grievance within 24 hours.

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.

The Quality Improvement Organization (QIO) is a group of doctors and other health care experts paid by the federal government to check on and help improve the care given to Medicare patients. They are not part of the Plan or the hospital. For Florida this organization is called KEPRO. The doctors and other health experts in KEPRO review certain types of complaints made by Medicare patients. These include complaints from Medicare patients who think their hospital stay is ending too soon.

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 QIO, or both. If you file with the QIO, we must help the QIO resolve the complaint.

You or your authorized representative may contact KEPRO by phone or in writing:

KEPRO
Area 2
5201 West Kennedy Boulevard, Suite 900
Tampa, Florida 33609
Toll-free Phone Number: 844-455-8708
Local Phone Number: 813-280-8256
Fax: 844-834-7129
Website:  https://www.keproqio.com/bene/statelisting.aspx?state=Florida