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Appeals & Grievances

As a member of MediGold, you have the right to file an appeal and/or grievance. An “appeal” is a request you may make for reconsideration of our determination on a service, supply or drug you have received or requested. You may file an appeal when you believe that the services or supplies should be covered or that they should be covered differently than MediGold approved or paid them. A “grievance” is a complaint that does not involve a coverage determination. For example, grievances may be filed if you are unhappy with the quality of care or service you receive from us or from our providers.

To obtain an aggregate number of grievances, appeals and exceptions filed with the plan, please call 1-800-240-3851 (TTY 711), 8 a.m. – 8 p.m., 7 days a week.

Please refer to your Evidence of Coverage (EOC) for information on coverage determinations:

2014 Evidence of Coverage 

2014 Essential Care (HMO) Evidence of Coverage

2014 Southeast OH Essential Care (HMO) Evidence of Coverage

2014 Southwest OH Essential Care (HMO) Evidence of Coverage

2014 Classic Preferred (HMO) Evidence of Coverage

2014 Southeast OH Classic Preferred (HMO) Evidence of Coverage

2014 Southwest OH Classic Preferred (HMO) Evidence of Coverage

2014 Medical Only (HMO) Evidence of Coverage

2014 Network Choice (PPO) Evidence of Coverage

2014 Value Choice (PPO) Evidence of Coverage

2014 Employer Group Health Plan (HMO) Evidence of Coverage - TIMKEN

2014 Employer Group Health Plan (HMO) Evidence of Coverage - CHE Trinity Health

Please know that you may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. Please call Member Services at 1-800-240-3851, 8 a.m. – 8 p.m., 7 days a week, to request an exception.

If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. 

Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. In Ohio, that organization is KePRO, and you may contact them at 1-855-408-8557.

Specific Information about Part D Appeals and Grievances

If you are a member of a MediGold plan that includes Part D drug coverage, you have the right to file a grievance related to your Part D drug benefits. Likewise, you may file an appeal. If you would like to file an appeal related to your Part D benefit, please call, fax or write to CVS Caremark (MediGold’s Pharmacy Benefit Manager). For more complete information about filing a Part D appeal or grievance, please refer to the Appeals and Grievances section of your Evidence of Coverage (EOC).

Contact Information (Part D Drug) Appeals:

CVS Caremark
Appeals Department
MC 109
PO Box 52000
Phoenix, AZ 85072-2000

Fax: 1-866-217-3353
Phone for “fast appeals”: 1-866-785-5714 (TTY 1-866-236-1069)

Request a Part D appeal online:

Part D Redetermination Online Request Form

Request an initial Part D coverage determination online:

Contact Information (Part D Drug) Grievances:

CVS Caremark
Grievance Department
PO Box 53991, MC121
Phoenix, AZ 85072-3991

Fax: 1-866-217-3353
Phone: 1-866-785-5714

Contact Information for all other Appeals and Grievances:

If you have a complaint that is NOT related to your Part D drug benefits, we encourage you to call our Member Service Department at 1-800-240-3851, 7 days a week, from 8 a.m. – 8 p.m.  You may also send an appeal or grievance letter to the following address or fax it to the number below:

Attn: Appeals and Grievance Coordinator
6150 East Broad Street, EE320
Columbus, OH 43213

Fax: (614) 546-3132

If you should need us to make a “fast” decision on such matters rather than a “standard decision,” please write to the address above or contact our Appeals and Grievance Coordinator through our Member Service Department. Please review the Appeals and Grievance information in our Member Agreement (Evidence of Coverage) for complete appeals and grievance information and guidance.

You can also contact MediGold’s Member Service Department for more information, about:

  • How we manage the use of services and costs;
  • The number of appeals and grievances filed by our members;
  • A summary description of how we pay our doctors; or
  • A description of our financial condition, including a summary of our most recent audit statement.

Appoint a Representative

You can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal. If you want a friend, relative, your doctor or other provider, or other person to be your representative, use the link below to complete the Appointment of Representative Form and send it to the same location where you are sending (or have already sent) your appeal, grievance or exception request.

Appointment of Representative Form

File a Complaint with Medicare

You can also submit a complaint about your Medicare health plan or prescription drug plan directly to Medicare using the Medicare Complaint Form.

Visit the Medicare Ombudsman Center to learn how the Office of the Medicare Ombudsman helps you with complaints, grievances and other requests.

Last Updated 9/4/2014 9:50:31 AM