Appeals and Grievances

What Is an Appeal?

An appeal is a formal request by the member (or his/her authorized representative) to change a decision previously made by Liberty Medicare Advantage.

For example, you may file an appeal for any of the following reasons:

• Liberty Medicare Advantage refuses to cover or pay for services you think Liberty Medicare Advantage should cover.
• Liberty Medicare Advantage or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
• Liberty Medicare Advantage or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
• If you think that Liberty Medicare Advantage is stopping your coverage too soon.

Who Can File an Appeal?

You or your authorized representative may file an appeal. You may also have your physician file an appeal on your behalf.

You may appoint an individual to act as your representative to file the grievance or an appeal for you by following the steps below.

Provide our health plan with:

1. Your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: “I [your name] appoint [name of representative] to act as my representative in requesting an appeal from Liberty Medicare Advantage and/or CMS regarding the denial or discontinuation of medical services.”
2. Your name, address and phone number and that of your representative, if applicable.
3. A signed and dated statement by you and the person you are appointing as representative.
4. You must include this signed statement with your appeal.
5. Reasons for appealing, and any evidence you wish to attach.
6. Supporting medical records, doctors’ letters, or other information that explains why your plan should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.

When Can an Appeal Be Filed?

You may file an appeal within sixty (60) calendar days of the date of the notice of the initial organization determination.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day time frame.

Can I Expedite an Appeal?

Yes, you may file an expedited grievance by calling: 1-844-854-6883 (TTY 711).

You have the right to request and receive expedited decisions affecting your medical treatment in “time-sensitive” situations.

A “time-sensitive” situation is a situation where waiting for a decision to be made within the time frame of the standard decision-making process could seriously jeopardize 1) your life or health, or 2) your ability to regain maximum function.

If Liberty Medicare Advantage decides, based on medical criteria, that your situation is “time-sensitive” or if any physician calls or writes in support of your request for an expedited review, Liberty Advantage or your Primary Care Physician will issue a decision as expeditiously as possible, but no later than seventy-two
(72) hours after receiving the request.

Where Can an Appeal Be Filed?

You may file a standard or fast appeal to: Liberty Medicare Advantage (HMO SNP), Appeals and Grievances Department, PO Box 3325, Spring Hill, FL 34611, Phone 1-844-854-6884 (TTY 711), Fax 1-877-760-3810.

What Happens Next?

We will review your appeal. If any of the services you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by a reviewer outside of Liberty Medicare Advantage. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.

What Is a Grievance?

A grievance is a type of complaint that does not involve payment or denial of services by Liberty Medicare Advantage or a Contracting Medical Provider. For example, you would file a grievance if:

• You have a problem with things such as the quality of your care during a hospital stay;
• You feel you are being encouraged to leave your plan;
• Waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room;
• Waiting too long for prescriptions to be filled;
• The way your doctors, network pharmacists or others behave;
• Not being able to reach someone by phone or obtain the information you need; or
• Lack of cleanliness or the condition of the office.

Who Can File a Grievance?

A grievance may be filed by any of the following:

• You may file a grievance.
• Your authorized representative

When Can a Grievance Be Filed?

You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance. There is no filing limit for complaints concerning quality of care. Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day time frame.

Can I Expedite a Grievance?

Yes, you may file an expedited grievance by calling: 1-844-854-6884 (TTY 711). If you disagree with Liberty Medicare Advantage’s decision to extend the timeframe on your organization determination or reconsideration, or Liberty Medicare Advantage’s decision to process your expedited request as a standard request. In such cases, you may file an expedited grievance and receive a response within twenty-four (24) hours of receipt.

Where can a Grievance Be Filed?

If you would like you can file a complaint directly to Medicare by filling out the complaint form at https://www.medicare.gov/MedicareComplaintForm/home.aspx. You may file a standard grievance in writing directly to: Liberty Medicare Advantage – Appeals and Grievances Department, PO Box 3325, Spring Hill, FL 34611, 2 by faxing 1-866-820-0690 or over the phone by contacting our Member Services Department at our toll-free number at 1-844-854-6884 (TTY 711).

How to Obtain an Aggregate Number of Appeals, Grievances, and Exceptions

You have the right to request the number of appeals and the number of quality of care grievances received by Liberty Medicare Advantage during a plan year. Please call Member Services at 1-844-854-6884 (TTY 711), Fax 1-877-760-3810. Calls to this number are free.

How to Appoint a Representative to File a Grievance or Complaint

You or someone you name may file a complaint (grievance) or appeal for you. The person you name would be your “appointed representative”. You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act on your behalf.

To appoint a representative, fill out the CMS Appointment of Representative Form (CMS Form-1696). Once you have filled out the form, you may print and mail the form to:

Liberty Medicare Advantage
PO Box 3325
Spring Hill, FL 34611

How to End your Liberty Medicare Advantage Benefits

Ending your Membership in Liberty Medicare Advantage may be voluntary (your own choice) or involuntary (not your own choice). If you are leaving our plan, you must continue to get your medical care through our plan until your Membership ends.

For more complete information about disenrolling from Liberty Medicare Advantage, you can do any of the following:

• See your Evidence of Coverage for more information and to learn about the rights, benefits, and responsibilities of Members.
• Read the Medicare & You Handbook. Everyone with Medicare receives a copy of Medicare & You each fall. Those new to Medicare receive it within a month after first signing up. You can also download a copy from the Medicare website (www.medicare.gov). Or, you can order a printed copy by calling Medicare at the number below.
• Contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Calls to these numbers are free.