Grievances and Appeals

Important Information About Your Appeal Rights for Services, Supplies and Non-Part D Drugs

There are 2 kinds of appeals

Standard Appeal – We’ll give you a written decision on a standard appeal within 30 calendar days after we get your appeal (or within 7 calendar days after we get your appeal for a Medicare Part B prescription drug). Our decision might take longer if you ask for an extension, or if we need more information about your case. We’ll tell you if we’re taking extra time and will explain why more time is needed. We can’t take extra time to make a decision if your appeal is for a Medicare Part B prescription drug. If your appeal is for payment of a service you’ve already received, we’ll give you a written decision within 60 calendar days.

Fast Appeal – We’ll give you a decision on a fast appeal within 72 hours after we get your appeal. You can ask for a fast appeal if you or your provider believe your health could be seriously harmed by waiting up to 30 calendar days for a decision.

We’ll automatically give you a fast appeal if a provider asks for one for you or supports your request. If you ask for a fast appeal without support from a provider, we’ll decide if your request requires a fast appeal. If we don’t give you a fast appeal, we’ll give you a decision within 30 calendar days (or within 7 calendar days after we get your appeal for a Medicare Part B prescription drug).

How to ask for an appeal with Neighborhood

Step 1: You, your representative, or your provider must ask us for an appeal. Your request must include:

• Your name
• Address
• Member number
• Reasons for appealing
• Any evidence you want us to review, such as medical records, doctors’ letters, or other information that explains why you need the item or service. Call your provider if you need this information.

You can ask to see the medical records and other documents we used to make our decision before or during the appeal. At no cost to you, you can also ask for a copy of the guidelines we used to make our decision.

Step 2: Mail, fax, or deliver your appeal or call us.

For a Standard Appeal:    

Address:
Grievance and Appeals Coordinator
Neighborhood Health Plan of Rhode Island
910 Douglas Pike
Smithfield, RI 02917

Phone: 1-844-812-6896
Fax: 1-401-709-7005

If you ask for a standard appeal by phone, we will send you a letter confirming what you told us.

For a Fast Appeal:  
Phone: 1-844-812-6896
Fax: 1-401-709-7005

What happens next?

If you ask for an appeal and we continue to deny your request for payment of a service, we’ll send you a written decision. The letter will tell you if the service or item is usually covered by Medicare and/or Medicaid.

• If the service is covered by Medicare, we will automatically send your case to an independent reviewer. If the independent reviewer denies your request, the written decision will explain if you have additional appeal rights.
• If the service is covered by Medicaid, you can ask for a State Fair Hearing. You may also ask for an External Review if the service you are requesting requires a medical necessity review. Both the State Fair Hearing and the External Review are conducted by independent entities that are not part of the plan. Your written decision will give you instructions on how to request an external review and/or State Fair Hearing.
• If the service could be covered by both Medicare and Medicaid, we will automatically send your case to the independent reviewer. You can also ask for a hearing with the RI External Review organization and/or State Fair Hearing office. Your written decision will give you instructions on how to request either or both of these appeal processes.

For more information about the appeals process, please refer to your Member Handbook or call Member Services at 1-844-812-6896 (TTY 711), 8 a.m. to 8 p.m., Monday – Friday; 8 a.m. to 12 p.m. on Saturday. On Saturday afternoons, Sundays and holidays, you may be asked to leave a message. Your call will be returned within the next business day.

Standard Part D Appeals

If you don’t agree with a decision we make about a prescription drug covered by Medicare, you have the right to appeal.

We’ll give you a written decision on a standard appeal within 7 calendar days after we get your appeal.

If your appeal is for payment of a drug you’ve already received and received a denial for, we’ll give you a written decision within 14 calendar days.

Fast (Expedited) Part D (Prescription Drug) Appeals

Sometimes waiting 7 calendar days for a coverage decision could seriously jeopardize your ability to attain, maintain, or regain maximum function. If you or your providers believe your request must be reviewed quickly, you can ask for a fast review, known as an expedited appeal, by contacting Member Services at 1-844-812-6896; TTY users should call 711. We are open 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday.

We will give you a decision on an expedited appeal within 72 hours after we get your appeal. If your prescriber asks for an expedited appeal for you, or supports you in asking for one, and indicates that waiting for 7 calendar days could seriously harm your health, we will automatically expedite your appeal.

If you ask for an expedited appeal without support from your prescriber, we will decide if your health requires an expedited appeal. We will notify you if we do not give you an expedited appeal and we will decide your appeal within 7 days.

To request a Part D (Prescription Drug) Appeal, call, mail, or fax your request to:

CVS Caremark Part D Appeals and Exceptions
PO BOX 52000 MC109
Phoenix, AZ 85072-2000

Phone: 1-844-812-6896
Appeals fax: 1-855-633-7673

To request reimbursement for a Part D Prescription you paid out of pocket for, please mail a copy of your receipt and related prescription documentation to:

CVS Caremark Part D Appeals and Exceptions
PO BOX 52066
Phoenix, AZ  85072-2066
Paper Claims Appeals fax: 1-855-230-5549

A Grievance is a type of complaint you make that will not usually involve coverage or payment for services. You would file a grievance if you had any type of problem with the quality of your medical care, waiting times, or the customer service you receive. You would also file a grievance if you did not think we had responded quickly enough to your request for coverage determination or organization determination, or to your appeal. Grievances are responded to with 30 calendar days.

Filing a Grievance

You or your appointed representative can file a grievance verbally by calling Member Services at 1-844-812-6896 (TTY 711), 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday. On Saturday afternoons, Sundays and holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free.

You can also submit a grievance in writing or in person.  Your request should include:

• Your name
• Address
• Neighborhood member identification number
• Reasons why you are not happy

To request a grievance, mail, or fax your request to:

Address:
Neighborhood Health Plan of Rhode Island
Grievances and Appeals Department
910 Douglas Pike
Smithfield, RI 02917

Phone:  1-844-812-6896
Fax: 1-401-709-7005

You can also submit a grievance:

• By calling Medicare 1-800-Medicare/TTY 1-877-486-2048. Calls to this number are free, 24 hours a day, 7 days a week.
• Online by visiting Medicare.gov

Appointing a Representative

If you need someone to file a grievance (a complaint) or appeal on your behalf, you can name a relative, friend, advocate, provider, or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

To appoint someone as your representative, download a copy of the Authorized Representative Form. Please complete it, and fax or mail it to:

Address:
Grievance and Appeals Coordinator
Neighborhood Health Plan of Rhode Island
910 Douglas Pike
Smithfield, RI 02917

Phone: 1-844-812-6896
Fax: 1-401-709-7005

Get help & more information:

If you need help or additional information about Neighborhood’s decision and the appeal process, call Member Services at 1-844-812-6896 (TTY 711), 8 a.m. to 8 p.m., Monday – Friday; 8 a.m. to 12 p.m. on Saturday. On Saturday afternoons, Sundays and holidays, you may be asked to leave a message. Your call will be returned within the next business day.

You can also contact the following for help and information:

• Medicare:  1-800-MEDICARE (1-800-633-4227 or TTY: 877-486-2048), 24 hours a day, 7 days a week
• Medicare Rights Center:  1-888-HMO-9050
• Elder Care Locator:  1-800-677-1116
• The POINT: 1-401-462-4444 (TTY: 711)

Contact Information

How to Obtain an Aggregate Number of Grievances, Appeals and Exceptions Filed with Neighborhood: To obtain an aggregate number of grievances, appeals and exceptions, please call Member Services at 1-844-812-6896 (TTY 711), 8 a.m. to 8 p.m., Monday – Friday; 8 a.m. to 12 p.m. on Saturday.

On Saturday afternoons, Sundays and holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free.

Legal Services (Rhode Island) 
1-401-274-2652

Rhode Island Insurance Resource, Education, and Assistance Consumer Helpline 
300 Jefferson Blvd, Suite 300
Warwick, RI 02888
Telephone: 1-855-747-3224 (1-855-RIREACH)
Web site: www.rireach.org 
E-mail: rireach@ripin.org

Helpful Links

• Appointment of Representative (AOR) Form
• Part D Redetermination Request Form
• Enrollee Appeal Request Form
• Enrollee Grievance Request Form
• File a complaint directly with CMS