Appeals and Grievances about your Medicare Advantage Benefits

For Appeals and Grievance information about your Part D Prescription Drug Benefits click here.

What to do if you have a complaint.

We encourage you to let us know right away if you have questions, concerns, or problems related to coverage or payment of a medical service or benefit.

Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from this plan or be penalized in any way for making a complaint.

A complaint will be handled as either a grievance or an appeal, depending on the subject of the complaint.

What if my plan denies any part of my request for coverage or payment of a medical service or benefit?

What is an appeal?
How to file an appeal
What if you want a fast appeal?
Appeals in special situations

What if I have a grievance about my plan?

What is a grievance?
What to do if you have a grievance
How to file a formal grievance
What if I want a fast grievance?

What if I want to appoint a representative to act on my behalf?

How to appoint a representative

What if I have questions about the appeal and grievance processes or the status of my appeal or grievance?

Questions about the appeal and grievance process

What if I want to review detailed appeal and grievance information contained in my plan's Evidence of Coverage (EOC)?

Detailed information about appeals and grievances

What is an appeal?

An appeal is any of the procedures that deal with the review of an unfavorable organization determination. If we issue an unfavorable organization determination, you may file an appeal, which is called a "reconsideration", if you want us to change our initial decision.

Here are some examples of organization determinations you may wish to appeal:

You are not receiving the care you want, and you believe that this care is covered by the plan.

We will not authorize the medical treatment your doctor or other medical provider wants to give you, and you believe that this treatment is covered by the plan.

You are being told that coverage for a treatment or service you have been getting will be reduced or stopped, and you feel that this could harm your health.

You have received care that you believe was covered by the plan while you were a member, but we have refused to pay for that care.

There are five levels to the appeals process. The first level is reconsideration by the plan. If our reconsideration decision is unfavorable, you have additional appeal rights.

How to file an appeal (reconsideration)

If you wish to file an appeal with the plan, you must do so within 60 calendar days from the date included on the notice of our organization determination.

You cannot request an appeal if we have not issued an organization determination.

For a standard request, you or your appointed representative may file the request in writing.

We will respond to your standard appeal about authorizing care you have not yet received no later than 30 calendar days after we receive your appeal. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

We will respond to your standard appeal about payment for care you already received no later than 60 calendar days after we receive your appeal.

You may fax, mail, or deliver your written appeal to us at:

Windsor Medicare Extra
Attn: Grievance & Appeals Department
7100 Commerce Way
Suite 285
Brentwood, TN 37027
Fax: (615) 782-7971

For your convenience, you may use the "Member Grievance and Appeal Form" to file an appeal with us.

Print the Member Grievance and Appeal Form (PDF).

Simply complete, sign, and date the form. You may fax, mail, or deliver the form to us as listed above. Please include any supporting documents you wish for us to consider when we process your appeal.

What if you want a fast appeal?

A fast appeal (also known as an "expedited" appeal) may be filed by you, your appointed representative, or any doctor by calling Member Services 7 days a week, from 7 a.m. to 8 p.m. at the numbers below. Remember, appeals must be filed within 60 calendar days.

Calls to these numbers are free:
Phone: 1-800-316-2273
TTY/TDD: 1-800-848-0298

Or you can file a written request for a fast appeal, as listed above. We will respond to your fast appeal no later than 72 hours after we receive it. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.

If you ask for a fast decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast appeal, we will send you a letter informing you that if you get a doctor's support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a "fast grievance" if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast appeal, we will give you our decision within the 30 calendar day standard timeframe.

Appeals in special situations

A. How to file an appeal if you think you are being discharged from the hospital too soon.

If you think that you are being discharged too soon, ask Windsor Medicare Extra to give you a notice called the Notice of Discharge & Medicare Appeal Rights. This notice will tell you:

Why you are being discharged.

The date that we will stop covering your hospital stay (stop paying our share of your hospital costs).

What you can do if you think you are being discharged too soon.

Whom to contact for help.

As explained in the Notice of Discharge & Medicare Appeal Rights, if you act quickly, you can ask an outside agency called the Quality Improvement Organization (QIO) to review whether your discharge is medically appropriate. The Notice of Discharge & Medicare Appeal Rights gives the name and telephone number of the QIO and tells you what you must do.

As the notice will explain, you must ask the QIO for a "fast review" no later than noon on the first working day after you are given written notice that you are being discharged from the hospital. This deadline is very important. If you meet this deadline, you are allowed to stay in the hospital past your discharge date without paying for it yourself, while you wait to get the decision from the QIO.

If you do not ask the QIO for a "fast review" ("fast appeal") of your discharge by the deadline, you can ask us for a "fast appeal" of your discharge as explained in the section What if you want a fast appeal above.

B. How to file an appeal if you think your coverage for skilled nursing facility (SNF), home health (HHA), or comprehensive outpatient rehabilitation facility (CORF) services is ending too soon.

If we decide to end our coverage for your SNF, HHA, or CORF services, you will receive written notice from either us or your provider at least 2 calendar days before your coverage ends. This notice is called a Notice of Medicare Non-Coverage.

As the notice will explain, you can ask the Quality Improvement Organization (QIO) to perform an independent review of whether our terminating your coverage is medically appropriate.

The written notice you will get from us or your provider gives the name and telephone number of the QIO and tells you what you must do.

If you get the notice 2 days before your coverage ends, you must be sure to make your request no later than noon of the day after you get the notice.

If you get the notice and you have more than 2 days before your coverage ends, then you must make your request no later than noon of the day before the date that your Medicare coverage ends.

After reviewing all the information, the QIO will give an opinion about whether it is medically appropriate for your coverage to be terminated on the date that has been set. The QIO will make this decision within one full day after it receives the information it needs to make a decision.

What is a grievance?

A grievance is any complaint other than one that involves an organization determination. You would file a grievance if you have any type of problem with us or one of our providers.

Examples of concerns that might lead you to filing a grievance:

Problems with the quality of the medical care you receive, including quality of care during a hospital stay.

Problems with the Member Service you receive.

Problems with how long you have to spend waiting on the phone, in the waiting room, or in the exam room.

Disrespectful or rude behavior by doctors, nurses, receptionists, or other staff.

Cleanliness or condition of doctor's offices, clinics, or hospitals.

What to do if you have a grievance.

If you have a grievance, we encourage you to first call Member Services for assistance. You may call Member Services 7 days a week, from 7 a.m. to 8 p.m. at the numbers below.

Calls to these numbers are free:
Phone: 1-800-316-2273
TTY/TDD: 1-800-848-0298

We will try to resolve any complaint that you have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this a "formal grievance".

How to file a formal grievance.

If you wish to file a formal grievance with the plan, you must do so within 60 calendar days of the event that led to your complaint.

You or your appointed representative may file a grievance either orally or in writing.

In general, we will respond to your grievance no later than 30 calendar days after we receive your grievance. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

You may fax, mail, or deliver your written grievance to us at:

Windsor Medicare Extra
Attn: Grievance & Appeals Department
7100 Commerce Way
Suite 285
Brentwood, TN 37027
Fax: (615) 782-7971

For your convenience, you may use the "Member Grievance and Appeal Form" to file a formal grievance with us.

Print the Member Grievance and Appeal Form (PDF).

Simply complete, sign, and date the form. You may fax, mail, or deliver the form as listed above. Please include any supporting documents you wish for us to consider when we process your formal grievance.

What if I want a fast grievance?

If you disagree with our decision not to expedite your request for an organization determination or appeal (reconsideration), you or your appointed representative may file a request for a fast grievance (also known as an expedited grievance) by calling Member Services 7 days a week, from 7 a.m. to 8 p.m. at the numbers below. Remember, grievances must be filed within 60 calendar days.

Calls to these numbers are free:
Phone: 1-800-316-2273
TTY/TDD: 1-800-848-0298

Or, you can file a written request for a fast grievance at the contact information listed above. We will respond to your fast grievance no later than 24 hours after we receive your fast grievance.

How to appoint a representative.

You can file an appeal or grievance by yourself or you may name someone to do it for you. The person you name would become your appointed representative.

You can name a relative, friend, advocate, doctor, or anyone else to act for you. Please note that your physician does not need to be appointed by you to request a fast appeal.

Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

For your convenience, you may use the "Appointment of Representative" form to appoint a representative.

Print the Appointment of Representative Form (PDF).

Simply, complete, sign, and date the form and include it with your appeal and/or grievance request.

You also have the right to have an attorney ask for an appeal on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.

Questions about the appeal and grievance processes or case status.

If you have any questions or concerns about the appeal and grievance processes, or wish to inquire on the status of your appeal or grievance, please call Member Services 7 days a week, from 7 a.m. to 8 p.m. at the numbers below for assistance.

Calls to these numbers are free:
Phone: 1-800-316-2273
TTY/TDD: 1-800-848-0298

Detailed information about appeals and grievances.

The information described above is a summary of the appeals and grievance process.

For a more detailed description of these processes, please refer to the Appeals and Grievances sections of your Evidence of Coverage (EOC).

You may access a copy of your Evidence of Coverage by clicking on View my benefits.