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Medicare Appeals Grievances

Lovelace has processes in place to address Medicare coverage issues, complaints and problems. If you have coverage issues related to medical or pharmacy services, or if you or your representative wish to file an appeal or grievance, please call our Customer Care Center at 505.727.5400 or toll free at 800.808.7363 seven days a week from 8:00 am to 8:00 pm. TTY/TDD: 711.

You may also contact us by fax at 505.727.5307, or in writing at:

Lovelace Senior Plan
Customer Care Center
P.O. Box 27107
Albuquerque, NM 87125

You have the right to make a complaint if you have concerns or problems related to your coverage or care. There are two different types of complaints:

• An appeal is the type of complaint you make when you want us to reconsider and change a decision we’ve made about the services or benefits we’ve covered for you or the amount we will pay for a particular service or benefit.
• A grievance is the type of complaint you make if you have any other type of problem with Lovelace Senior Plan.

Appeals

If we deny coverage or payment for an item, medical service or prescription that you think we should cover or pay for, you may request an appeal.

• You can ask us to “expedite an appeal” (give you a quick decision) if we denied coverage for a service.
• If we deny coverage for a drug that you think should be covered, or if you think it should be covered on a different tier, you may request an “exception.”
• If you think you are being discharged from the hospital too soon, you may ask for a “Notice of Discharge and Appeal Rights.”
• If you think that your covered services in a skilled nursing facility, home health or comprehensive outpatient rehabilitation facility are ending too soon, you may ask for a “fast-track” appeal.

Grievances

If you have a complaint related to the quality of care you receive, the timeliness of services or any other concern except for the coverage or payment issues listed above, you may file a grievance.

Filing an Appeal or Grievance

If you or your representative want to file an appeal or grievance, you may contact the Lovelace Appeals Department at the above numbers or address. You may also contact the appeals department if you want information about the number of appeals and grievances filed with the plan.

Appointing a Representative

If you would like someone to act for you on an appeal or grievance – a family member, advocate, physician or friend – you may appoint that person to represent you. To give permission to the person to act on your behalf, you must sign and date either a Medicare Appointment of Representative Form or a Lovelace Appointment of Representative Form. Your representative must also sign and date the statement unless he or she is an attorney. Please fax your completed and signed form to 505.262.7719 or mail it to:

Lovelace Customer Service
4101 Indian School Road NE
Albuquerque, NM 87110

Pharmacy Coverage Determinations and Drug Exception Requests

You may request a coverage determination related to your pharmacy coverage benefit. You, your representative or your prescribing physician may request a coverage determination, including a tiering or formulary exception, by calling the Customer Care Canter at 505.727.5400 seven days a week from 8:00 am to 8:00 pm. TTY/TDD: 711.

You may also fax us at 505.262.7390, or write to us at:

Lovelace Senior Plan
Customer Care Center
P.O. Box 27107
Albuquerque, NM 87125

Prior Authorization

Your physician or an office staff member may request a pharmacy prior authorization step therapy or non-formulary drug exception request, by faxing the form to 505.262.7390.

Pharmacy Appeals and Grievances

For details on the pharmacy appeals and grievance process, please see Chapter 12 of your Evidence of Coverage or click on the links below.

• Pharmacy Appeals Information
• Medicare Redetermination Requests and Form

If you do not agree with a coverage determination decision, including a pharmacy coverage decision made, and want to appeal that decision, you, your doctor or your representative should contact Lovelace Customer Care Center at 505.727.5400 or 800.808.7363 seven days a week from 8:00 am to 8:00 pm. TTY/TDD: 711.

You may also contact us by fax at 505.262.7390, or in writing at:

Lovelace Senior Plan
Customer Care Center
P.O. Box 27107
Albuquerque, NM 87125

You may request a standard appeal to which we will provide a response within 7 calendar days, or you may file a fast appeal if you or your doctor feel that a standard appeal could seriously harm your health or ability to function. If we determine that your appeal should be treated as a fast appeal, we will provide our decision within 72 hours. You may use the Medicare Redetermination Request Form to file your appeal.