Grievances
Let us know your complaints.
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 items, services, or prescription drugs, regardless of whether remedial action is requested or can be taken. A grievance does not include, and is distinct from, a dispute of the appeal of an organization determination or coverage determination or an LEP determination. Please consider that you should notify us within 60 calendar days after the issue or incident that cause the complaint, either in written or through phone.
Part C
- An enrollee’s involuntary disenrollment initiated by the plan;
- A change in premiums or cost sharing arrangements form one contract year to the next;
- Plan benefit design;
- The appeals process;
- General dissatisfaction about a co-payment amount, but not a dispute about the amount the enrollee paid or is billed.
Part D
- Plan benefit design;
- The appeals process;
- General dissatisfaction about a co-payment amount, but not a dispute about the amount the enrollee paid or is billed;
- General issue about a drug not being on the formulary or listed as an excluded drug;
- Calculation of True Out-of-Pocket (TrOOP) costs.
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 Medicare and Much More
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: 888-317-0751
Fax: 844-878-7921
Website: https://www.keproqio.com/bene/statelisting.aspx?state=Florida
