Grievances and Member Feedback
Health Choice Generations is committed to maintaining high levels of member satisfaction. We continuously strive to improve our services through member feedback.
We encourage our members who require assistance with problem solving, to call our Member Services Department at 1-800-656-8991, 8 am – 8 pm, 7 days a week. (TTY for the hearing impaired: 711).
Another avenue is to use the grievance process.
Note:
You may file a Grievance verbally (over the phone) by calling Health Choice at 1-800-656-8991. Or, you may also write a letter to Health Choice and either mail or fax it to:
Health Choice Generations
Attn: Quality Management
410 N. 44th Street, Ste. 900
Phoenix, AZ 85008
Fax: 480-303-4433
Some examples of situations when you would file a complaint:
- The quality of services that you receive
- Office waiting times
- Physician behavior
- Adequacy of facilities
- Involuntary disenrollment issues
- Any other areas of dissatisfaction that do not include coverage decisions
Or you may file an expedited (24 hour) grievance when you disagree with Health Choice Generations decision to:
- Extend the time frame to make an initial decision or appeal (also called a reconsideration).
- A refusal to grant your request for a fast initial decision (A fast initial decision is a decision in 24 hours for Part D drugs OR a decision in 72 hours for medical services or supplies you have not yet received); OR
- A refusal to grant your request for a fast appeal (72 hours).
If your complaint is about a decision regarding the denial of services or payment, you will need to file an appeal. Please refer to your Evidence of Coverage (EOC) for detailed instructions on how to file an appeal or call Health Choice Generations Member Services at 1-800-656-8991, 8 am – 8 pm, 7 days a week (TTY for hearing impaired: 711).
If you should have any questions regarding the information and/or procedures above, please call Health Choice Generations at 1-800-656-8991. TTY users should call 711. Or, you may e-mail the plan at Comments@steward.org.
Filing a complaint with Medicare
You can also file a complaint directly through Medicare by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, or by visiting the Medicare complaint website at Medicare.gov.
Organization Determinations
An organization determination is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. See Chapter 9 of your Evidence of Coverage for complete details about this process. We are making an organization determination whenever we decide what is covered for you and how much we pay. You or your doctor can contact us and ask for an organization determination if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need.
When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard organization determination means we will give you an answer within 14 calendar days after we receive your request. If your health requires it, ask us to give you a “fast” organization determination, which is an expedited organization determination. An expedited organization determination means we will answer within 72 hours. You can get an expedited organization determination only
- if you are asking for coverage for medical care you have not yet received.
- if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If you ask for an expedited organization determination on your own, without your doctor’s support, we will decide whether your health requires such, which may require contacting your doctor.
How to request a determination for the medical care you want
Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this.
- CALL 1-800-656-8991 – Calls to this number are free. Hours of operations are 8 a.m. to 8 p.m. seven days a week, Monday – Sunday.
- TTY 711 – This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Hours of operations are 8 a.m. to 8 p.m. seven days a week, Monday – Sunday.
- FAX – 1-877-424-5680.
- WRITE – Health Choice Generations, Attn: Prior Authorization, 410 N 44th Street, Suite 510 Phoenix, AZ 85008
Appeal Process
An “appeal” is the type of complaint you make when you want us to reconsider and change a decision we have made about what medical services or benefits are covered for you or what we will pay for a medical service or benefit.
You can ask us for an initial decision or you can appoint someone to do it for you; this person would be your Authorized Representative. For more information about Authorized Representatives, please refer to your HC Generations Evidence of Coverage.
There are six possible steps you can take to make complaints related to your medical coverage or payment for your medical care.
At each step, your request is considered and a decision is made. The decision may be partly or completely in your favor or it may be completely denied. If you are unhappy with the decision there may be another step you can take to get further review of your request. Whether you are able to take the next step may depend on the dollar value of the medical care involved or other factors.
If you are unhappy with the decision at any step of the process, you may be able to take another step if you want to continue requesting the care or payment.
- In Steps 1 and 2, you make your request directly to us. We review it and give you our initial decision. If our initial decision is to turn down your request, you can go on to Step 2 where you appeal this initial decision.
- In Steps 3 through 6, your appeal goes outside of HC Generations where people who are not connected to us make the decisions about your request. To keep the review independent and impartial, those who review the request and make the decision in Steps 3 through 6 are part of (or in some way connected to) the Medicare program or the federal court system.
Standard Decisions vs. Fast Decisions about Medical Care
A decision about whether HC Generations will cover medical care can be a standard decision that is typically made within 14 days or it can be a fast decision that is typically made within 72 hours.
You can ask for a fast decision only if you or any doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. Fast decisions apply only to requests for medical care and you cannot get a fast decision on requests for payment for care you have already received.
Prescription Drug Benefit Appeal
If you wish to dispute a decision regarding your Prescription Drug benefit, there is a separate process called “Coverage Re-determination”. Please refer to your HC Generations Evidence of Coverage.
How to file an Appeal
If you are asking for a Standard Decision, you have the right to initiate an appeal verbally by telephone at 1-800-656-8991 (TTY users call 711). You or your authorized representative can also submit your Appeal in writing to:
Health Choice Generations
Attn: Pharmacy Appeals
410 N 44th Street Ste 900
Phoenix, AZ 85008
For more information about filing an appeal, please see Chapter 2, section 1 of your Evidence of Coverage.
If you are asking for a Fast Decision, you, any doctor or your authorized representative can do so verbally by telephone by calling 1-800-656-8991 (TTY users call 711).
Note:
You, any doctor or your authorized representative should have available any necessary documentation to support your request for a fast decision.
Appointment of Representative
If you would like to appoint a person to file a grievance or request an appeal on your behalf, you and the person accepting the appointment must complete this form. Submit the completed form with the grievance or appeal request.
If you have further questions, about appointing someone to speak or make healthcare decisions on your behalf contact Health Choice Generations Member Services, 8 am – 8 pm, 7 days a week, at 1-800-656-8991 (TTY users call 711).
Appointment of Representative Form (Spanish)