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Appeals and Grievances
What is an Appeal?
Appeals are procedures that deal with the review of an unfavorable coverage determination. You can file an appeal if you want us to reconsider a decision we have made regarding Part D prescription drug benefits or cost sharing associated with Part D drug coverage.
- “Standard” Appeal Decision: We have up to 7 calendar days from the time we receive your request to make a decision on a “standard” appeal.
- “Fast” Appeal Decision: For a “fast” appeal decision for a Part D drug you have not received may take up to 72 hours from the time we receive your request.
What is a Grievance?
A grievance is any complaint or dispute (dissatisfaction) other than one involving an organization determination. It is different from a coverage determination request; it usually will not involve coverage or payment for Part D drug benefits.
- Grievance decisions will be made as quickly as your case requires but no later than 30 calendar days after receiving your complaint.
- If you request a “fast” grievance, a decision will be rendered within 24 hours.
How Do I Request an Appeal or Grievance?
To check status or to request a “Standard”, “Fast” or “Expedited” Appeal or Grievance: You, your appointed representative or your prescribing physician should contact us by telephone, fax, mail or hand deliver at the numbers or address below:
Phone: 503-574-8000 or 1-800-603-2340
Fax: 503-574-8646 or 1-800-249-7714
Mail To:
Providence Medicare Plans
Attn: Appeals and Grievance Department
P.O. Box 4327
Portland, OR 97208-4327
Hand Deliver To:
Providence Medicare Plans
Attn: Appeals and Grievance Dept.
3601 SW Murray Blvd., Suite 10
Beaverton, OR 97005
If you have Medicare prescription drug coverage (Part D) with Providence, please refer to your Member Handbook/Evidence of Coverage Section 12, “Getting information to support your appeal”.
Contact Information
If you need additional information or help, please call us at: Toll Free: 503-574-8000 or 1-800-603-2340 TTY: 503-574-8702 or 1-888-244-6642.
Other Resources to Help You
Medicare Rights Center
Toll Free: 1-888-HMO-9050
Elder Care Locater
Toll Free: 1-800-677-1116
1-800-Medicare
(1-800-633-4227)
TTY: 1-877-486-2048
Providence Health Plan is a health plan with a Medicare Advantage contract.
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