Appeals, Grievances and Coverage Decisions

Sometimes you might need a formal process for dealing with a problem you are having as a member of our plan. There are three types of processes for handling problems and concerns about medical or prescription drug benefits:

  • Coverage Determinations
  • Appeals
  • Grievances

Contact Us

  • For information on how to obtain an aggregate number of grievances, appeals and exceptions for our plan.
  • If you have questions about the status of an appeal, grievance, or coverage determination request.
  • For more details about these processes
Call Customer Service at 1-866-789-7747; TTY: 711
7 days a week, 8 am - 8 pm

October 1 - March 1

Monday - Friday 8 am - 8 pm
March 2 - September 30
TTY users should call 711

What is a Medical Coverage Determination and when do I use it?

A medical coverage determination (also called a “coverage decision”) is a decision we make about your benefits and coverage or about the amount we will pay for your medical services.

If you are having problems getting medical care, a service you requested, or payment for medical care or services you have already received (including the amount you have already paid), then you make a Coverage Determination request. If you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage determination for you. If we say no, you have the right to ask us to reconsider - and perhaps change – this decision by making an appeal.

If your health requires a quick response, ask us to make a "fast decision." To get a fast coverage decision, you must meet two requirements:

  • You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care you have already received.)
  • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function
  • How do I make a request for a medical coverage determination?

    To request a Medical Coverage Determination you, your doctor, or your representative may:

    • Call Customer Service:1-866-789-7747; TTY: 711
    • Fax:1-844-612-4062
    • Write: Soundpath Health
      Medical Coverage Decisions
      Attn: Care Management
      12615 Chenal Parkway
      Suite 300
      Little Rock, AR 72221

    • Here are all the resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:

      • You can call us at Customer Service (phone numbers are listed on this page).
      • You can contact your State Health Insurance Assistance Program to get free help from an independent organization that is not connected with our plan. Contact information is noted in your Evidence of Coverage.
      • Your doctor can make a request for you.
      • You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.
        • There may be someone who is already legally authorized to act as your representative under State law.
        • If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Customer Service and ask for the “Appointment of Representative” form. (The form is also available on our website and Medicare’s website https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Cms-Forms-Items/CMS012207.html) (This link will direct you to a new website) The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.
      • You also have the right to hire a lawyer to act for you.

      What is a Prescription Drug (Part D) Coverage Determination and when do I use it?

      A Part D coverage determination (coverage decision) is a decision we make about your prescription drug benefits and coverage or about the amount we will pay for your drugs. For example, assigning a cost-sharing level (or Tier) to each of our covered drugs is a coverage decision made by our plan.

      If a drug is not covered in the way you would like it to be covered, if you need us to waive a rule or restriction on a drug we cover, or if you want us to change coverage of a drug to a lower cost-sharing tier, you can ask us to make an “exception”. This is one type of coverage determination request. To request an exception, your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception. Another example of when you might make a Part D coverage determination request is if you have a problem getting payment for prescription drugs you have already received (including the amount you have already paid). If we turn down your request for any type of coverage determination, you can appeal our decision.

      If your health requires a quick response, ask us to make a "fast coverage decision." To get a fast coverage determination, you must meet two requirements:

      • You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.)
      • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

      How do I make a request for a Part D coverage determination?

      To request a Prescription Drug (Part D) Coverage Determination you, your doctor, or your representative may:

      • Call OptumRx: 1-844-368-7174; TTY: 711
        24 hours a day/7days per week
      • Fax: 1-800-527-0531
      • Write:
        OptumRx
        Prior Authorization Department
        P.O. Box 25183
        Santa Ana, CA 92799

      Here are the resources you may wish to use if you decide to ask for any kind of Part D coverage decision or appeal a decision:

      • Call, write, or fax us to make your request. You, your representative, or your doctor (or other prescriber) can do this.
      • If you want to ask us to pay you back for a drug, call Customer Service for the paperwork, or go to our Member Center web page to download the Prescription Drug Reimbursement Request form.
      • If you are requesting an exception, provide the “supporting statement.” Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. (We call this the “supporting statement.”) Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary.
      • You may submit a request on the Part D Coverage Determination Request form, which is available on our 2018 Prescription Drug Information web page.
      • You may submit a 2018 request electronically by accessing the "ONLINE Part D Coverage Determination Requests through Optum Rx" link on our 2018 Prescription Drug Information web page.

      How do I find out more information about my health plan's appeals, grievance and coverage determination process?

      You may contact Customer Service with any questions or concerns. Also, your Evidence of Coverage (EOC) document has a chapter about appeals, grievances and coverage determination processes. It is called “What to do if you have a problem or complaint (coverage decisions, appeals, complaints).” You will find information about different situations where you might want to ask us for a coverage decision, deadlines for us to give you our decision, detailed how-to steps, and more.

      What is an Appeal and when do I use it?

      If we make a coverage decision and you are not satisfied with our decision or part of our decision, you or your representative can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. If your health requires a quick response, you must ask for a "fast appeal." When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the benefits properly. When we have completed the review we will give you our decision in writing. If we say no to all or part of your Level 1 Appeal, your appeal will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our Plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal. These additional levels are explained in your Evidence of Coverage.

      To file an Appeal you or your representative may:

      • Call:1-866-789-7747; TTY: 711
      • Fax:1-877-899-2790
      • Write: Soundpath Health
        Attn: Appeals & Grievance Dept.
        PO Box 27510
        Federal Way, WA 98093

      • Link to Appeal Request Form (This link will direct you to a new website)

      What is a Grievance and when do I use it?

      A grievance is any complaint, other than one that involves a request for an initial determination or an appeal as described in the determinations and appeals section of your Evidence of Coverage. If you have a complaint about quality of care, waiting times, or the customer service you receive, you or your representative may call 1-866-789-7747 (TTY users should call 711). We will try to resolve your complaint over the phone. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the Soundpath Health Grievance Procedure. To use the formal grievance procedure, you may submit your written grievance to our Appeals & Grievance Department. If you file a written grievance, or your complaint is related to quality of care and we have your consent to investigate, we will respond in writing to you.

      Appointing a Representative - You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call Customer Service or you may click here for the Appointment of Representative Form. (This link will direct you to a new website)

        To file a Grievance you or your representative may:

        • Call:1-866-789-7747; TTY: 711
        • Fax:1-877-899-2790
        • Write: Soundpath Health
          Attn: Appeals & Grievance Dept.
          PO Box 27510
          Federal Way, WA 98093

        • For quality of care problems, you may also complain to the Quality Improvement Organization (QIO)

          You may complain about the quality of care you received, including care during a hospital stay. You may complain to us using the grievance process, to the Quality Improvement Organization (QIO), or both. If you file with the QIO, we must help the QIO resolve the complaint. Please refer to Chapter 2 of your Evidence of Coverage for additional information about the Quality Improvement Organization in your state.

          Medicare Complaint Form - If you have complaints or concerns about the Soundpath Health Medicare Advantage Plan and would like to contact Medicare directly please use the following link www.Medicare.gov.  Or call them at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. (Note: This link takes you to a different site.)

          The Medicare Beneficiary Ombudsman - The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests. (Note: This link takes you to a different site.)

          Appointing a Representative - You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call Customer Service or you may click here for the Appointment of Representative Form. (This link will direct you to a new website)

          If you would prefer that someone else act on your behalf, please fill out this form, sign it and return it to us.

          • Call:1-866-789-7747: TTY: 711
          • Fax:1-877-899-2790
          • Write: Soundpath Health
            Attn: Appeals & Grievance Dept.
            PO Box 27510
            Federal Way, WA 98093

          • For more detailed information regarding appeals, grievances and coverage determinations, please refer to your Evidence of Coverage chapter on “What to do if you have a problem or complaint (coverage decisions, appeals, complaints)”. To access Soundpath Health's Evidence of Coverage documents, click the button below


             


Page Last Updated: January 01, 2019