Submitting an appeal or grievance

What to know about Grievances, Appeals and Coverage Determinations

Here is some quick information about:

Grievances
Appeals
Coverage determinations

Go to your plan's Evidence of Coverage (EOC) to get full details about each of these.

What is a grievance?

A grievance (or complaint) is the way you can tell us you’re unhappy about something with our plan. You can file a complaint with us about:

Poor customer service (from us or our providers)
The quality of care received from a provider in our network
Privacy issues
Long wait times for doctor appointments, when calling into Customer Service, or our response to an appeal or coverage determination
Information provided by our Customer Service team

What else should I know about complaints?

Medicare has rules around grievances that we must follow:

You have up to 60 calendar days after the problem occurs to make a complaint.
You cannot be disenrolled from your plan for making a complaint.
Your complaint will always be handled fairly and investigated following Medicare rules.

How do I file a complaint?

There are several ways you can make a complaint:

Call Customer Service. Our customer service number is on the back of your Arkansas Blue Medicare member ID card. We will try to fix the problem the first time you call us. If we can’t, we may take up to 30 calendar days.
Write to us. Mail your complaint to: Arkansas Blue Medicare P.O. Box 3648 Little Rock, AR 72203
Fax your complaint to 501-301-1928 .

You can also make a complaint directly to Medicare. Go to https://www.medicare.gov/my/medicare-complaint and complete the online form.

What is an appeal?

An appeal is asking us to review, and change, our decision not to cover a service, item, or prescription.

What else should I know about appeals?

Medicare also has rules around appeals that we must follow:

You have up to 65 calendar days after you get our written denial notice to ask for an appeal.
We must answer your request within a certain amount of time.

We must reply withing:

For an appeal about a medical service you’re waiting to get: 30 days
For an appeal about a Part B or Part D drug you're waiting to get: 7 days
For an appeal about a payment for a Part B or Part D drug you already purchased: 30 days
For an appeal about a medical service you already received or payment for a service you already paid for: 60 days

What if I can’t wait that long for a response?

You can ask for a fast appeal. For it to be considered a fast appeal:

It must be for a medical service or Part B or Part D drug you have not yet received
You or your provider feel waiting could cause serious harm to your health or hurt your ability to function

We have to reply to fast appeals within:

72 hours if it’s for a medical service
24 hours if it’s for a Part B or Part D drug

Please note: It’s best to have your provider or pharmacist ask for a fast appeal.

How do I file an appeal?

Call Customer Service. Our customer service number is on the back of your Arkansas Blue Medicare member ID card.
Write or fax.

For an appeal about a medical service or Part B drug, mail/fax to:

Arkansas Blue MedicareAttn: Medicare AppealsP.O. Box 2181Little Rock, AR 72203Fax: 1-501-301-1928

For an appeal about a Part D drug, mail/fax to:

CVS Caremark Part D Appeals & ExceptionsP.O. Box 52000, MC109Phoenix, AZ 85072-2000Fax: 1-855-633-7673

What is a coverage determination (also called an organization determination)?

A coverage determination is the plan’s decision on what is covered and how much we will pay.

What else should I know about coverage determinations?

Medicare also has rules around coverage determinations that we must follow:

We must reply to your request for a coverage determination within a certain amount of time:

For a coverage determination about a medical service you’re waiting to get, we must reply within 14 calendar days.
For a coverage determination about a Part B or Part D drug you’re waiting to get, we must reply within 72 hours.

What if I can’t wait that long for a response?

You can ask for a fast decision on your coverage determination. For it to be considered a fast decision:

You or your provider feel waiting could cause serious harm to your health or hurt your ability to function

We have to make fast decisions on coverage determinations within:

72 hours if it’s for a medical service you have not yet received
24 hours if it’s for a Part B or Part D drug you have not yet received

Please note: It’s best to have your provider or pharmacist ask for a fast coverage determination.

How do I ask for a coverage determination?

Have your provider or pharmacist ask for one.
If your provider or pharmacist doesn’t ask for you, you can call Customer Service. Our customer service number is on the back of your Arkansas Blue Medicare member ID card.
Write or fax.

For a coverage determination about a medical service or Part B drug, mail/fax to:

Arkansas Blue MedicareP.O. Box 3648Little Rock, AR 72203Fax for medical services: 1-816-313-3014Fax for Part B drugs: 1-816-313-3015

For a coverage determination about a Part D drug, mail/fax to:

CVS Caremark Part D Appeals & ExceptionsP.O. Box 52000, MC109

Phoenix, AZ 85072-2000

Fax: 1-855-633-7673

What if I would like someone else to file a grievance, appeal, or coverage determination for me?

You can have someone acting on your behalf file a grievance, appeal, or coverage determination.
This person would be your representative.
To appoint someone as your representative, we must have a completed Appointment of Representative form on file for you.
We won’t be able to start the process without this form.
You can get the form at https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms1696.pdf .
Please note: Your provider does not need to complete an Appointment of Representative form if she/he is asking for an appeal or coverage determination for you.

How do I check the status of a complaint, appeal, or coverage determination?

Call Customer Service. Our customer service number is on the back of your Arkansas Blue Medicare member ID card.
Ask for the status of the grievance, appeal, or coverage determination you or your representative filed.

Part D Drug Coverage Determination Forms

More Information

If you would like to know how many grievances, appeals, and coverage determinations have been filed with us, call us. Call 1-844-463-1088 (TTY: 711 ). Our hours are listed below.