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SD Grievances and Appeals for Part C

Grievances and Appeals for Part C

Member appeals and grievances process

Senior Dimensions

Members of our Medicare Advantage health plans have the right to request an organization determination, as well as the right to file an appeal and the right to file a grievance. Medicare Advantage health plan organizations must identify, track, resolve, and report all activity related to an appeal or grievance.

Medicare Advantage member appeals

Organization determination

Pre-service organization determination:

  • Standard organization determination: within fourteen (14) calendar days of receipt of the request
  • Expedited organization determination: within seventy-two (72) hours of receipt of the request

Post-service organization determination:

  • You will be provided written notification within thirty (30) calendar days of receipt of the request

What is an appeal?

An appeal is a type of request you can make asking us to reconsider a decision about coverage of a service, or the amount your health plan pays or will pay for a service. The initial decision concerning medical care or services is called an organization determination.

When can I file an appeal?

You may file an appeal within sixty (60) calendar days from the date of the initial organization determination, or within sixty (60) days of the Health Plan's written notice that a payment was not made. The deadline may be extended if you have a valid reason for missing it. In your written appeal, explain why you missed the deadline.

Can someone file an appeal for me?

Yes, someone else can file an appeal on your behalf. If someone files an appeal on your behalf, you must appoint the individual to act as your representative. To name another person as your representative to request an appeal, contact Customer Service toll-free at 1-800-650-6232, TTY 711 to request an Appointment of Representation (AOR) form. Customer Service hours: October 1 - February 14: 8 a.m. - 8 p.m. local time, 7 days a week. February 15 - September 30: 8 a.m. - 8 p.m. local time, Monday - Friday. On Saturday, Sunday, and holidays, please leave a detailed message and a representative will return your call within one business day. You may obtain a copy of the AOR form online 24 hours a day by clicking here (Published August 1, 2018). The form must be completed, signed by you and the person you would like to act on your behalf and returned to:

Health Plan of Nevada, Inc.
Senior Dimensions 
P.O. Box 14865
Las Vegas, NV 89114-5645

Or

Fax: 702-266-8813

How do I file an appeal?

You must file a standard appeal in writing directly to:

Health Plan of Nevada, Inc.
Senior Dimensions
P.O. Box 14865
Las Vegas, NV 89114-5645

Or

Fax: 702-266-8813

Health Plan of Nevada processes all requests for appeals according to the following time frames:

  • Pre-service reconsideration: You will be provided written notification of the outcome within thirty (30) calendar days of receipt of the request.
  • Post-service or payment reconsideration: You will be provided written notification within sixty (60) calendar days of receipt of the request.
  • Expedited reconsideration: When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your request. We will give you our answer sooner if your health requires us to do so.

If the enrollee or enrollee's representative requests an extension, or if additional information is needed and the delay is in the interest of the enrollee, the thirty (30) calendar day time frame for pre-service reconsideration may be extended up to fourteen (14) calendar days.

For expedited appeal, the fourteen (14) calendar day extension can be applied if applicable.

Fast appeals

You may request and receive a fast decision on your appeal if waiting for a decision to be made in the standard time frame could seriously harm your health or your ability to function. If your doctor gives us a supporting statement in writing or verbally, we will automatically give you a fast appeal. A decision will be made as soon as possible but no later than seventy-two (72) hours after we receive your request.

Expedited appeal/fast appeal requests can be submitted in writing to the above address or made verbally to Customer Service toll-free at 1-800-650-6232, TTY 711. If you are calling outside of Customer Service business hours to request an expedited review or fast appeal, please call the Customer Response and Resolution Department (CR&R) at 702-242-7839 or toll-free at 1-800-578-6757, TTY 711. If you receive our voice mail message, your telephone call will be returned within 24 hours.

Note: Fast appeals do not include Post-service or payment reconsideration requests (payment for a service or benefit you have already received).

Medicare Advantage member grievances

What is a grievance?

A grievance is a complaint that's not about coverage for an item or service. For example, you would file a grievance if you were unhappy with your quality of care, wait times on the phone or at a network facility, or staff behavior at a network facility. If your complaint is about quality of care, you have the right to file a grievance with the Quality Improvement Organization (QIO) of your state. Refer to Chapter 2, Section 4 of the EOC for the name of the QIO in your state.

When can I file a grievance?

You may file a grievance within sixty (60) calendar days from the date of the event that concerns your grievance. Through the QIO there is no deadline for grievances about quality of care.

Can someone file a grievance for me?

Yes, someone else may file a grievance on your behalf. Before someone files a grievance on your behalf, you must appoint the individual to act as your representative. To name another person as your representative to file a grievance, simply contact Customer Service toll-free at 1-800-650-6232, TTY 711 to request an Appointment of Representation (AOR) form. You may obtain a copy of the AOR form online 24 hours a day by clicking here (Published on: August 1, 2018). The form must be completed, signed by you and the person you would like to act on your behalf and returned to:

Health Plan of Nevada, Inc.
Senior Dimensions 
P.O. Box 14865
Las Vegas, NV 89114-5645

Or

Fax: 702-266-8813

How do I file a grievance?

You may file a grievance verbally by contacting Customer Service toll-free at 1-800-650-6232, TTY 711.

A quality of care grievance, or a grievance that is made in writing to, Health Plan of Nevada, Inc., Senior Dimensions, P.O. Box 14865, Las Vegas, NV 89114-5645, will be responded to in writing.

Other verbal grievances may be responded to verbally or in writing, if requested.

Time frames for grievances

We must address grievances as quickly as each case requires, based on your health status, but no later than thirty (30) calendar days after receiving a grievance.

Fast grievances

You have the right to file a fast grievance. We'll respond to fast grievances within twenty-four (24) hours of receipt. You may file a fast grievance if you disagree with our decision to deny your request for a fast appeal. You may also file a fast grievance if you disagree with our decision to extend our time frame for making an organization determination or appeal decision.

You can also review your Evidence of Coverage for appeals and grievance information. To access your Evidence of Coverage from this website, click here. Appeals and grievance information is listed under Chapter 9 of the Evidence of Coverage. For information on how to obtain an aggregate number of appeals, grievances, and exceptions filed with the plan, please contact Customer Service. If you have questions or would like to inquire about the status of an appeal, you or your provider may call Senior Dimensions toll-free at 1-800-650-6232, TTY 711.

Find out how to appoint a representative.