Coverage Decisions, Appeals & Grievances

Appeals

As a member, you have the right to file an appeal when you want us to re-evaluate and change a decision we have made about what benefits are covered for you or what we will pay for a benefit. Your appeal must be filed within 60 calendar days from the date on the denial letter you received. In some situations, we may accept your appeal beyond 60 days if you show good cause for an extension.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the benefits properly. When we have completed the review we will give you our decision in writing.

An appeal may be filed by you or your appointed representative* in the following ways:

• By calling Customer Service toll free at 877-672-8620 (TTY 711). You may also use this number to check on the status of an existing appeal.
• By completing the Online Appeal Request Form.
• By completing an Appeal Request Form and mailing or faxing the completed form back to us.
  ATRIO Health Plans
  PO Box 5600
  Scranton, PA 18505
  Fax: 866-339-8751

*To appoint a representative for appeals, please complete the CMS Appointment of Representative Form (CMS Form-1696) and include a signed copy with your appeal. The appointment is valid for one year unless revoked.

Grievances

A grievance is any complaint, other than one that involves a request for a coverage determination or an appeal. Examples of a grievance include a complaint about quality of care, waiting times, or the customer service you receive. The grievance must be submitted within 60 days of the event or incident. ATRIO must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.

You can file grievances and complaints, including those related to marketing, in person or by mail, fax, or email. If you need help filing a grievance or complaint, contact Customer Service toll free at 1-877-672-8620, daily from 8 a.m. to 8 p.m.. TTY users should call 711. To file a grievance or complaint with Medicare, contact 1-800-MEDICARE, 24 hours a day/7 days a week. If filing a marketing complaint with ATRIO or Medicare, please provide your agent/broker name if possible.

A grievance may be filed by your or your representative* in the following ways:

• By calling Customer Service toll free at 877-672-8620 (TTY 711). One of our representatives will try to resolve your complaint over the phone. You may also use this number to check on the status of an existing grievance.
• By completing the Online Grievance Request Form.
• By completing the Grievance Request Form and mailing or faxing the completed form back to us.
  ATRIO Health Plans
  PO Box 5600
  Scranton, PA 18505
  Fax: 866-339-8751

*To appoint a representative for appeals, please complete the CMS Appointment of Representative Form (CMS Form-1696) and include a signed copy with your grievance. The appointment is valid for one year unless revoked.

Members can also file a complaint directly with Medicare by going to Medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY/TTD users can call 1-877-486-2048.

To obtain an aggregate number of ATRIO Health Plan's grievances, appeals and exceptions, please call Customer Service at 877-672-8620 (TTY 711).