Appeals and Grievances

You have the right to make a complaint if you have concerns or problems related to your coverage or care. "Appeals" and "grievances" are the two different types of complaints you can make and are discussed below. For a full explanation of medical and prescription drug coverage decisions, formulary exceptions, medical and prescription drug appeals, and grievances, see your Evidence of Coverage:

Care Assured Value Plan
Care Assured Value Plus Plan
Care Assured Premier Plan
Care Assured Premier Plus Plan

Medical Care Appeals
If a health care service or claim is denied, or if HealthMarkets Care Assured fails to provide you with a timely organization determination, you have the right to file an appeal in writing. If the denial could jeopardize your health status, you may request an expedited appeal by phone or fax. A medical care decision is called an "organization determination" by the Medicare program.

The first level of medical appeal is a "reconsideration" and is conducted by the plan's health care professionals and physicians. HealthMarkets Care Assured must gather information and make a decision within a 30-day time period, or within 72 hours for expedited appeals. Time extensions are possible. Claims are decided within 60 days.

If HealthMarkets Care Assured upholds its initial denial, we send the appeal automatically to Medicare's independent review contractor. This second level appeal is also called a reconsideration. If the independent reviewer agrees with the health plan's denial, you have the same rights to all federal levels of appeals and judicial review as do beneficiaries in fee-for-service Medicare. Organization determinations may be "standard" or "expedited." (An expedited decision may be requested if the determination is time-sensitive and a delay could jeopardize your health.) You, your physician, or an appointed representative may request a determination, standard or expedited, by HealthMarkets Care Assured orally or in writing. Claims for services obtained outside of the network or service area should be mailed to the address below.

Requests may be made by a family member, friend, or other party if the individual demonstrates legal authority, such as a medical power of attorney. Another way to be delegated this authority is by submitting a signed Appointment of Representative form to us.

If a service or claim is denied by HealthMarkets Care Assured, you should receive a notice that explains the denial and your appeal rights. If certain services such as a hospitalization, a stay in a skilled nursing facility, or home health services are about to stop and you believe you still require this level of care, you should receive a notice explaining your rights.

In addition to the information in your Evidence of Coverage, you may contact Member Services.

Prescription Drug Appeals
Coverage decisions are “determinations” about what tests, treatment services, and prescription drugs are covered or paid for under your health plan. These decisions are guided by Medicare coverage guidelines as well as what is medically necessary, appropriate, and safe. Your physician makes most decisions about your medical care, and HealthMarkets Care Assured works with providers to help assure that you receive the covered benefits you need.

You can read about coverage decisions for medical care in the section that follows. In the Medicare Information section of the web site you can read more about prescription drug decisions.

Grievances
If you are dissatisfied or have a complaint about any aspect of HealthMarkets Care Assured, you may call or write our Member Services department. Complaints other than those involving organization are called grievances. (Complaints about denials and other adverse organization are handled as appeals, and are not grievances.) We will investigate the grievance and respond to you in a timely manner. Complaints about denied requests for an expedited decision or appeal, or disagreements over time extensions, will be handled as expedited grievances - they are reviewed and resolved within 24 hours.

Coverage Decisions
For medical care organization determinations and authorizations, contact us at
Phone: 1-877-219-5458 (TTY/TDD: 1-800-409-8640).
Fax: 215-238-2503.

Appeals
To obtain a standard medical care appeal, please send your written appeal request to HealthMarkets Care Assured, either by mail to:

HealthMarkets Care Assured
Attn: Member Services
P.O. Box 13652
Philadelphia, PA 19101-3652

Or, by fax to: 1-888-289-3008.

To obtain an expedited medical care appeal, contact us at
Phone: 1-877-219-5458 TTY: 1-800-409-8640
Fax: 1-888-289-3008

Grievances
To file a grievance/complaint (standard or expedited) you can write to us at the address above or call Member Services at 1-877-219-5458 TTY: 1-800-409-8640.

Additional Information
As a HealthMarkets Care Assured member, you may request:

Additional information from the Centers for Medicare and Medicaid Services by calling 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048), which is the national Medicare help line, 24 hours a day, 7 days a week.

The aggregate number of HealthMarkets Care Assured grievances and appeals can be available to you by calling Member Services.

Enter your ZIP CODE to review Care Assured Plans in your area.

Appeals and Grievances