Appeals and Grievances

Filing an Appeal or Grievance from someone other than the member requires an AOR form to be attached to the member's case. Follow the steps as outlined per process.

In processing an Appeals and Grievance (A&G) call, it is important to ensure that the Aspire Health Plans (AHP) A&G Department has all of the necessary documentation of the call in order to complete the process and meet the health needs of AHP member. It is important that CSR follows the same outline in order to have an effective process.

Definition of Terms

Appeal: When the member is complaining about a decision the plan has made regarding the denial of a service, an item or of the payment of claims. Appeals can be the dispute of a cost share (copay or co-insurance) for services already received.

  • Coverage Determination - Any decision made by or on behalf of a Part D plan sponsor regarding payment or benefits to which an enrollee believes he or she is entitled. If the call center should receive a CD request, please warm transfer to MedImpact (888) 495-3160.

  • Organizational Determination - An initial decision made to determine whether the plan or its designee will provide or pay for services, in whole or in part, including the type or level of services. This may include the reduction or termination of services and the failure of the plan to approve, furnish, arrange for or provide payment for health care services in a timely manner, or to provide the member with timely notice of an adverse determination, such as a delay would adversely affect the health of the member.


Grievance: Any complaint or dispute, (other than one that constitutes an Organization or Coverage Determination), where the Member, a Member Representative, an Authorized Representative, or Agent expresses dissatisfaction with any aspect of a Medicare Advantage organizations or providers operations, activities or behavior, regardless of whether remedial action is requested.

Below are some of the general call scenarios one may receive. Match as closely as possible in order to guide the call through the specific process. Clicking on the Blue Links will walk you through the steps for processing A&G calls

Provider is not a specialist, so member believes they should not be responsible for a specialist copay.

Member received an Explanation of Benefits which states that copay is XX amount for a benefit but disagrees and believes the copay should be YY amount.

Plan denied member request for a referral/authorization and they do not agree.

Member claim was denied for no authorization and does not agree since they had approval from their PCP.

Grievance

Member expresses general dissatisfaction with plan benefit design.

Member expresses dissatisfaction with the plan with regard to either a specific issue or an overall dissatisfaction: Quality of Service

    • Providers office was dirty

    • Member didn't receive a call back from provider

    • Transportation vendor failed to return to pick member up after visit

    • Member missed radiation therapy due to transportation vendor arriving two hours late

Member expresses dissatisfaction with the Quality of Care already provided.

  • Doctor gave the wrong prescription

  • Eyeglasses prescription was wrong and can't see out of new glasses

  • Nurse placed medicated eye drops in the wrong eye during office visit

Member expresses dissatisfaction with benefits already provided.

Not Handled by A&G | Sent to A&G in Error

Provider requests to extend authorization: Document in CIM and warm transfer during business hours to UM Dept. 1(831) 657-0700.

Organizational Determinations (Part C): Route call to CSR II for distribution. (Ask Emily)

Coverage Determinations (Part D) Warm transfer to MedImpact: (888) 495-3160.

Member needs a drug that is not on the plan's list of covered drugs. Member would likely not have a Prescription.