Grievance and Appeals

There are four types of problems and concerns:
• Grievance
• Coverage Determination
• Organization Determination
• Appeals
 

A grievance is any complaint, other than one that involves a request for an initial determination or an appeal as described in the determinations and appeals section of your Evidence of Coverage. Examples of grievances include:

• You are involuntarily disenrolled from AlohaCare Advantage Plus
• Change in cost sharing from one contract year to the next
• Change in premiums from one contract year to the next
• Difficulty in reaching AlohaCare Advantage Plus on the telephone
• Difficulty in reaching your provider on the telephone
• Quality of care of services provided
• Interpersonal aspects of care
• Provider staff behavior
• Rudeness
• Failure to respect an enrollee's rights

Grievances must be filed within 60 days of the event or incident. You may send a complaint to us in writing or by calling Member Services. If you wish to appoint someone to act on your behalf, you must complete an Appointment of Representative form and send it to us with your grievance.

We 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 may request an expedited grievance if you disagree with our decision to:

• Not grant you an expedited appeal.
• Not grant you an expedited determination.
• Extend the standard review period of an initial decision or appeal.

We will promptly acknowledge that we received your expedited or "fast grievance" within 24 hours. A resolution to your grievance will be accomplished in the timeliest manner but no more than 72 hours from the time of our receipt.

If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.

To file a grievance or to ask process or status questions you or your representative may:

• Call 808-973-6395 or toll free at 1-866-973-6395
• TTY/TDD: 1-877-447-5990
• Fax: 1-800-830-7222
• Write: AlohaCare Advantage Plus
  Attn: Grievance & Appeals Division
  1357 Kapi`olani Blvd, Suite G101
  Honolulu, HI 96814
• File a Member Grievance Form

A coverage decision is the initial decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We are making a coverage decision anytime we decide what is covered for you and how much we will pay. If you are having problems getting medical care, a service you requested, or payment (including the amount you have already paid) for medical care or services you have already received, then you can resolve the problem through a coverage decision. If your health requires a quick response, you should ask us to make a "fast decision." If we say no, you have the right to ask us to reconsider - and perhaps change - this

• Request for Medicare Prescription Drug Coverage Determination: request a drug that is not covered by our formulary.
• Medicare Redetermination Request Form: let us know if you disagree with a Medicare drug determination decision we made.
   
  To request a Coverage Decision or to ask process or status questions you, your doctor, or your representative may:
• Call 808-973-6395 or toll free at 1-866-973-6395
• TTY/TDD: 1-877-447-5990
• Fax: 1-800-830-7222
• Write: AlohaCare 
  Attn: Grievance & Appeals Division
  1357 Kapi`olani Blvd, Suite G101
  Honolulu, HI 96814

If we make a coverage decision and you are not satisfied with our decision or part of our decision, you or your appointed representative can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. If your health requires a quick response, you may ask for a "fast appeal."

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.

If we say no to all or part of your initial appeal, there are additional levels of appeal outside our plan. If we deny your appeal, we will inform you about pursuing your appeal further. Also, these additional levels are explained in your Evidence of Coverage in Chapter 9 (“What to do if you have a problem or complaint (coverage decisions, appeals, complaints)”).

To file an appeal or to ask process or status questions you or your representative may:

• Call 808-973-6395 or toll free at 1-866-973-6395
• TTY/TDD: 1-877-447-5990
• Fax: 808-973-2140
• Write: AlohaCare 
  Attn: Grievance & Appeals Division
  1357 Kapi`olani Blvd, Suite G101
  Honolulu, HI 96814

Expedited Appeals

You can call us at our toll-free phone: 1-877-973-0712 and ask for an expedited appeal.

For an after-hours expedited appeals request you can call us at 808-356-5959.

If we decide that you do need an expedited appeal, we will make a decision and give you an answer within 72 hours. We will also call you with our decision and then will send you a letter with our decision in writing.

If we think that we need more information in order to do a more complete review, we will ask you if we can take more time (up to 14 days). We will let you know of any extension verbally and in writing. If you do not agree with the extension, we will make a decision within 72 hours using the information currently available.

You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call Member Services. If you would prefer that someone else act on your behalf, please fill out this form, sign it and return it to us.

• Appointment of Representative Form
• Protected Health Information Form

For quality of care problems, you may also complain to the Quality Improvement Organization (QIO). You may complain about the quality of care you received, including care during a hospital stay. You may complain to us using the grievance process, to the Quality Improvement Organization (QIO), or both. If you file with the QIO, we must help the QIO resolve the complaint.

• For Hawai`i, the Quality Improvement Organization is called Livanta.
• Call: 1-877-588-1123
• TTY/TDD: 1-855-887-6668
• Fax: 855-694-2929
• Mailing Address: Livanta BFCC-QIO Program
  10820 Guilford Road, Suite 202
  Annapolis Junction, MD 20701

If you have complaints or concerns about AlohaCare Advantage Plus and would like to contact Medicare directly, please use the following information. By clicking on the link, you will be leaving the AlohaCare website.

• CMS Complaint Form
• Call 1-800-MEDICARE

If AlohaCare denies coverage or payment for a prescription drug, you have the right to appeal our decision. You have 60 days from the date of the denial notice to submit your appeal.Your physician or provider prescribing the medication can submit an appeal for you. Anyone other than the prescriber, like a family or friend, must be your representative.If you need help completing this form or if you have questions about the appeal process, call AlohaCare’s Member Services Department at 808-973-6395 on Oahu or 1-866-973-6395 toll-free.To appeal any of your Medicare Drug denials, please fill-out this form: https://alohacare.na2.echosign.com/public/esignWidget?wid=CBFCIBAA3AAABLblqZhB1JYh3xowa3YoVTzWxlo0Edn04pDtOiFIwBH6AhPGGLcZ9lXAWmjfyO5mMcoQMX0M*

 

The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances and information requests. By clicking on the link, you will be leaving the AlohaCare website.

• Medicare Beneficiary Ombudsman Website

Please refer to chapter nine of AlohaCare Advantage Plus' Evidence of Coverage (EOC) (“What to do if you have a problem or complaint (coverage decisions, appeals, complaints)”) for more information regarding coverage decisions, appeals, and grievances processes.

You may contact Member Services with any questions or concerns including how to obtain information regarding the aggregate number of grievances, appeals, and exceptions filed with AlohaCare’s Medicare Advantage Plan.

 

AlohaCare Advantage Plus (HMO SNP) Members 

 

Call: 808-973-6395