Medicare Advantage Part C Medical Care Plan Rights

This section describes your Part C medical plan rights including grievances, coverage decisions, exceptions and appeal processes. For more detailed information, refer to Chapter 9 of the Evidence of Coverage.

Your Part C Medical Care Plan Rights

You have certain rights concerning your medical care. Specifically, you have the right to request a coverage decision, make an appeal to deal with problems related to your benefits and coverage for medical services including problems related to payment, and file a grievance regarding quality of care or other issues.

Time Frames for Standard and Expedited Reviews for Coverage Decisions

Standard Deadlines

Generally we use the standard deadlines for giving you our decision.
When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard decision means we will give you an answer within 14 days after we receive your request.

  • However, we can take up to 14 more days if you ask for more time, or if we need information (such as medical records) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.

  • If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.

Fast Decision

If your health requires it, ask us to give you a "fast decision."

A fast decision means we will answer within 72 hours.

However, we can take up to 14 more days if we find that some information is missing that may benefit you, or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing.

If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. We will call you as soon as we make the decision.

To get a fast decision, you must meet two requirements:

  • You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)

  • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor tells us that your health requires a "fast decision," we will automatically agree to give you a fast decision.

  • If you ask for a fast decision on your own, without your doctor's support, our plan will decide whether your health requires that we give you a fast decision.

If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter that says so (and we will use the standard deadlines instead).

This letter will tell you that if your doctor asks for the fast decision, we will automatically give a fast decision.

The letter will also tell how you can file a "fast complaint" about our decision to give you a standard decision instead of the fast decision you requested.

Step 2: Our plan considers your request for medical care coverage, and we give you our answer.

Deadlines for a "fast" coverage decision:

Generally, for a fast decision, we will give you our answer within 72 hours.

As explained above, we can take up to 14 more days under certain circumstances. If we take extra days, it is called "an extended time period."

If we do not give you our answer within 72 hours (or if there is an extended time period, by the end of that period), you have the right to appeal.

  • If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period.

  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Deadlines for a "standard" coverage decision:

Generally, for a standard decision, we will give you our answer within 14 days of receiving your request.

We can take up to 14 more days ("an extended time period") under certain circumstances.

If we do not give you our answer within 14 days (or if there is an extended time period, by the end of that period), you have the right to appeal.

  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period.

  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal.

  • If our plan says no, you have the right to ask us to reconsider—and perhaps change—this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want.

  • If you decide to make an appeal, it means you are going on to Level 1 of the appeals process.

For More Information

If you have any questions about these procedures, call Member Service at 1-800-200-4255 (TTY: 1-800-522-1254), from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week.

Additional information on these processes is also included in your Evidence of Coverage.