To file a grievance with Medicare you may call 1-800-Medicare (1-800-633-4227), available 24 hours a day, the seven days of the week. TTY (hearing impaired) users should call 711. You may also access the Medicare Grievance Form.
Plans are expected to disclose grievance, and appeals, upon request, to individuals eligible to elect a Medicare Advantage organization or a Part D Sponsor. If you are interested in receiving this information, please contact our Member Services Department.
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 grievance, either in written or through phone.
In certain cases, you have the right to ask for an “expedited grievance,” meaning your grievance will have a resolution within 24 hours. For example, if your grievance 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. If not, we must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your grievance. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.
For more information about Grievances, please refer to Chapter 9 of your Evidence of Coverage.
If we deny any part of your request for coverage or payment or if you disagree with our coverage determination, you may ask us to reconsider our decision. This is called an “appeal” or a “request for redetermination”. If you want to appeal, you must request your appeal within 60 calendar days from the date included on the notice of our coverage determination.
|Request for Redetermination of Medicare Prescription Drug Denial- Appeal||Download|
You or someone you name to act on your behalf (your appointed representative) may request an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. You must complete the Appointment of Representative Form.
How soon we decide on your appeal depends on the type of appeal. For an expedited (fast) decision about a Part D drug that you have not received, we have up to 72 hours to make a decision. For a standard redetermination, we have up to 7 calendar days and for a reimbursement redetermination Part D drug that you have paid, we have up to 14 calendar days. You or your appointed representative may contact us by telephone or fax at the numbers below:
MMM of Florida
Appeals and Grievances
Telephone: 1-844-212-9858 (Toll free), 711 (TTY)
Hours of Operation: Monday to Sunday, 8:00 a.m. to 8:00 p.m.
If you are notified that a prescription drug has not been approved, and you do not agree, you have the right to ask us to reevaluate your case. You may do so through this website. To protect your privacy and confirm your identity, an MMM of Florida representative might contact you, your physician or authorized representative, to ask you for more information or additional documentation.
For a standard decision, which may include the reimbursement for a Part D drug you already paid for and received, we have up to 14 calendar days to respond. We may answer before that time if it is determined that your health requires us to. You or your appointed representative may mail your written appeal to the following address:
MMM of Florida
Appeals and Grievances
P.O. Box 260430
Miami, FL 33126
For more information about how the Appeals Process works, including details of the five levels of the process please refer to the Evidence of Coverage of your plan.