Grievances and appeals

Grievances

Grievances

You have the right to file a grievance, or complaint, about us or one of our plan providers for matters other than payment or coverage disputes.

Examples of grievances include:

  • The customer service you receive
  • Waiting too long on the phone, waiting room, in the exam room or when getting a prescription
  • The length of time required to fill a prescription or the accuracy of filling a prescription
  • The quality of care you received from a provider or facility

Grievances must be filed within 60 days of the event or incident. You may send a complaint to us in writing or by calling Customer Service. If you wish to appoint someone to act on your behalf, you must complete an appointment of representative form (PDF) and send it to us with your grievance form (PDF).

We must notify you of our decision about your grievance within 30 calendar days after receiving your grievance.

Contact information
Medicare Advantage/Medicare Part D Appeals and Grievances
PO Box 1827, MS B32AG
Medford, OR 97501

FAX_Medicare_Appeals_and_Grievances@regence.com

Oral coverage decision requests
1 (855) 522-8896

To request or check the status of a redetermination (appeal): 1 (866) 749-0355

Fax numbers
Appeals and grievances: 1 (888) 309-8784
Prescription coverage decisions: 1 (888) 335-3016

Coverage decisions
A coverage decision is a decision we make about what we’ll cover or the amount we’ll pay for your medical services or prescription drugs.

Examples of coverage decisions include:

  • Formulary exceptions*
  • Copayment tiering exceptions*
  • Requests to find out if a medical service or procedure is covered

We respond to pharmacy requests within 72 hours for standard requests and 24 hours for expedited requests.** We respond to medical coverage requests within 14 days for standard requests and 72 hours for expedited requests. Coverage decision requests can be submitted by you or your prescribing physician by calling us or faxing your request. If you wish to appoint someone to act on your behalf, you must complete an appointment of representative form and send it to us with your prescription coverage determination form.

*If you are asking for a formulary or tiering exception, your prescribing physician must provide a statement to support your request. You cannot ask for a tiering exception for a drug in our Specialty Tier. In addition, you cannot obtain a brand-name drug for the copayment that applies to the generic drug.

**If you, or your prescribing physician, believe that waiting for a standard decision (which will be provided within 72 hours) could seriously harm your life, health or ability to regain maximum function, you can ask for an expedited decision. If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing or through a phone call to us) that he or she agrees that waiting 72 hours could seriously harm your life, health or ability to regain maximum function, we will give you a decision within 24 hours. If you do not obtain your physician's support, we will decide if your health condition requires a fast decision.

Appeals

Appeals

You have the right to appeal, or request an independent review of, any action we take or decision we make about your coverage, benefits or services. You can submit your appeal online, by email, by fax, by mail, or you can call using the number on the back of your member ID card. There are several levels of appeal, including internal and external appeal levels, which you may follow. Contact us as soon as possible because time limits apply.

Appeal online

Complete and send your appeal entirely online.

Appeal by email, mail or fax

Download a form to use to appeal by email, mail or fax.

What is an appeal?

When we make a decision about what services we will cover or how we’ll pay for them, we let you know. Usually we will send you an Explanation of Benefits (EOB) statement or a letter explaining our decision about a pre-authorization request. An appeal is a request from a member, or an authorized representative, to change a decision we have made about:

  • Access to health care benefits, including a pre-authorization request denial
  • Claims payment, handling or reimbursement for health care services
  • Other matters included in your plan's contract with us or as required by state or federal law

Who is a member?

A member is:

  • A person who has bought insurance for themselves (also called a contract holder) and any dependents they choose to enroll
  • Someone who has insurance through an employer, and any dependents they choose to enroll

Who can appeal?

The member can appeal, or a representative the member chooses, including an attorney or, in some cases, a doctor.

How to appeal

You can appeal a decision online; in writing using email, mail or fax; or verbally. You must appeal within 60 days of getting our written decision. Be sure to include any other information you want considered in the appeal. If the decision was after the 60-day timeframe, please include the reason you delayed filing the appeal.

Appropriate staff members who were not involved in the earlier decision will review the appeal. Once that review is done, you will receive a letter explaining the result.

You can also get information and assistance on how to submit an appeal by calling the Customer Service number on the back of your member ID card.

To appeal online today

You can send your appeal online today through DocuSign.

To appeal by email, mail or fax

Use the appeal form below. Instructions are included on how to complete and submit the form. You can also get information and assistance on how to submit a written appeal by calling the Customer Service number on the back of your member ID card.

To appeal verbally

Call the phone number on the back of your member ID card. Customer Service will help you with the process.

To request or check the status of a redetermination (appeal)

Call 1 (866) 749-0355.

More information

For member appeals that qualify for a faster decision, there is an expedited appeal process.

An appeal qualifies for the expedited process when the member or physician feels that the member's life or health would be jeopardized by not having an appeal decision within 72 hours. We will accept verbal expedited appeals. Please contact the Medicare Appeals Team at 1 (866) 749-0355 or submit the appeal in writing and stating you need a “fast,” “expedited,” or “hot" review, or a similar notation on the paperwork.

If requested, we will supply copies of the relevant records we used to make our initial decision or appeal decision for free. Those documents will include the specific rules, guidelines or other similar criteria that affected the decision.

For any appeals that are denied, we will forward the case file to MAXIMUS Federal Services for an automatic second review. MAXIMUS Federal Services is a contracted provider hired by the Center for Medicare and Medicaid Services (also known as CMS) and has no affiliation with us. MAXIMUS will review the file and ensure that our decision is accurate. If MAXIMUS disagrees with our decision, we authorize or pay for the requested services within the timeframe outlined by MAXIMUS.

Questions?

If you have any questions about your member appeal process, call our Customer Service department at the number on the back of your member ID card.

People with a hearing or speech disability can contact us using TTY: 711.

Para asistencia en español, por favor llame al teléfono de Servicio al Cliente en la parte de atrás de su tarjeta de miembro.

Para humingi ng tulong sa Tagalog, pakitawagan ang numero ng telepono ng Serbisyo sa Kostumer (Customer Service) na nakasulat sa likod ng inyong kard bilang miyembro.

如需中文幫助,請撥打客戶服務電話, 號碼位於您會員卡背面。

Diné kʼehjí áká'eʼyeedgo, t'áá shǫǫdí áká anídaalwoʼí bi béésh bee haneʼé ninaaltsoos bee atah nílínígíí bineʼdę̀ę̀ bikááʼ.

Your rights and responsibilities regarding disenrolling

  • You must continue to use network pharmacies until you are disenrolled from our plan to receive prescription drug coverage under our formulary.
  • You have the right to make a complaint if we ask you to leave our plan.
  • You may only disenroll or switch prescription drug plans under certain circumstances.

Additional rights

To obtain information on the aggregate number of grievances, appeals and exceptions filed with the plan contact Customer Service.


Contacting Medicare directly

You can submit feedback about your Medicare health plan or prescription drug plan directly to Medicare. The Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program.


Download forms

Find forms that will aid you in the coverage decision, grievance or appeal process. Click on your plan, then choose the Grievances & appeals category on the forms and documents page.

Get grievances & appeals forms >


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Last updated 10/01/2022
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