To speak with a licensed agent call 1-844-324-0691 (TTY 711)

Appeals & Grievances


As a member of Vibra Health Plan PPO, you have the right to fair and prompt handling of your problems.  There are rules, forms, and deadlines that must be followed by us and by you.

Appeals

There are two types of appeals:

  • A reconsideration is a review of an adverse organization determination on the Medicare Part C health care services you believe you are entitled to receive.
  • A redetermination is a review of an adverse coverage determination on Medicare Part D benefits you believe you are entitled to receive.

Grievances

A grievance is any complaint or dispute expressing dissatisfaction with the plan or one of our network providers or pharmacies, including a complaint about the quality of your care.

If your problem relates to an organization determination or a coverage determination, please follow the process for submitting an appeal request outlined below.

How to File Appeals and Grievances

For Part C Appeals

To appeal an adverse organization determination on Medicare Part C items or services OR to file a grievance with Vibra Health Plan, you can use our Member Appeal & Grievance Form. This form, along with any documentation to support your appeal or grievance, can be submitted by mail, fax or phone to:

Vibra Health Plan
ATTN: Appeals & Grievances
PO Box 60250
Harrisburg, PA 17106-0250
Fax: 1-844-774-5585
Phone: 1-844-388-8268 (TTY 711)

For Part D Appeals

To appeal an adverse coverage determination on Medicare Part D benefits, you can use our Redetermination Request Form. This form, along with any documentation to support your appeal, can be submitted by mail, fax or phone to:

Prime Therapeutics, LLC
Attention: Medicare Appeals Department
1305 Corporate Center Drive
Building N10
Eagan, MN 55121
Fax: 1-800-693-6703
Phone: 1-855-457-1352 (TTY 711)

If your health requires a quick response, you should ask us to make a "fast appeal", also known as an "expedited reconsideration". You, your doctor, or your representative can request a "fast appeal" by contacting us at the address, fax, or phone number listed above.

Vibra Health Plan requires an Appointment of Representative Form (or acceptable alternate proof of legal representation such as a court order or Power of Attorney) for anyone (e.g., a spouse, family member, friend, lawyer or caregiver) who the member wishes to designate as a representative to request an appear or grievance or act on his/her behalf.

For more information on how to file appeals and grievances, please see Chapter 9 of your Evidence of Coverage.

Time Frame for Filing Appeals and Grievances

You must file your appeal or grievance within 60 calendar days from the date of the initial determination or the date of the event. We may extend the time frame for filing an appeal or grievance if you have a good reason why the request was not filed timely.

Non-Contract Provider Appeal Rights

Non-contract providers have the right to request a reconsideration of a denial of payment. The reconsideration request must be filed within 60 days from the remittance notification date and must include a signed Waiver of Liability Statement holding the enrollee harmless regardless of the outcome of the appeal. This form, along with any documentation to support your appeal, can be submitted by mail or fax to:

Vibra Health Plan
ATTN: Appeals & Grievances
PO Box 60250
Harrisburg, PA 17106-0250
Fax: 1-844-774-5585

Additional Information

You may choose to file a complaint directly to Medicare about Vibra Health Plan by using the Medicare Complaint Form or by calling 1-800-Medicare.

For questions about the complaint process or to file a complaint by phone, you may contact Member Services at 1-844-388-8268 (TTY 711).

To request data on the total number of grievances, appeals, and exceptions filed with Vibra Health Plan, you may contact us at 1-844-388-8268 (TTY 711).

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Preferred method of contact

Tell us where you live.

Medicare beneficiaries may also enroll in Vibra Health Plan through the CMS Medicare Online Enrollment Center located at https://www.medicare.gov.

To view your coverage options, enter your zip code and county below.

Your location

We're sorry, but you have either entered an incorrect zip code or you are out of our service area.

Required field

Vibra Health Plan is a PPO with a Medicare contract. Enrollment in Vibra Health Plan depends on contract renewal.

Before you enroll

To make sure you are eligible we'll need a few more pieces of information.

Before your enroll

You must have Medicare Part A and Part B to join a Medicare Advantage Plan.

Generally you are not eligible to enroll in our plan if you have been medically determined to have ESRD. If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, you are eligible to enroll, we will need to contact you to obtain additional information.

Are you new to Medicare?

Are you already entitled to Part A and enrolled in Part B?

Do you have end-stage renal disease ESRD?

If you have had a successful kidney transplant and/or you don't need regular dialysis any more, please mail a note or records from your doctor showing you have had a successful kidney transplant or you don't need dialysis, otherwise we may need to contact you to obtain additional information.

Vibra Health Plan, Inc.

4000 Crums Mill Rd.

Suite 201

Harrisburg, PA 17112
To speak with a licensed agent call 1-844-324-0691 (TTY 711)

8 am - 8 pm Mon - Fri (Mon - Sun from 10/15/16 to 2/14/17)

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View Plan Options

Please select one of our coverage options below.

Your options
Plan Monthly Premium Primary Care Copay Out-of-pocket Max Select
Essential Coverage PPO$0In $10 | Out $35$6,700
Enhanced Coverage PPO$49.50In $5 | Out $25$4,800

Do you want to add optional dental coverage?

Your monthly rate will increase by $33.30.

For more details pertaining to the optional dental benefits, please see the Summary of Benefits.

Your monthly rate will increase by $28.00.

For more details pertaining to the optional dental benefits, please see the Summary of Benefits.

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Ready to Enroll?

It looks like you are interested in the plan outlined below. By clicking the “Enroll Now” button, you are confirming your intent to complete an actual enrollment request to join Vibra Health Plan.

You will want to have your Medicare card available to help complete the application.

If you need assistance during this process, our contact information is listed below.

Plan Breakdown

  • Primary Care Copay In $10 | Out $35
  • Out-of-pocket Max $6,700

Estimated monthly payment:

  • Monthly Premium $0
  • Monthly Dental Premium (Optional) $33.30

  • Monthly Total ${[{ mec.formatMonthlyTotal('Essential_Coverage_PPO') }]}
  • Primary Care Copay In $5 | Out $25
  • Out-of-pocket Max $4,800
  • Monthly Premium $49.50
  • Monthly Dental Premium (Optional) $28.00

  • Monthly Total ${[{ mec.formatMonthlyTotal('Enhanced_Coverage_PPO') }]}
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Important Information

You may enroll in only one Medicare Advantage Plan at a time.

You may join or leave that plan only at certain times of the year or in special circumstances.

The Annual Election Period occurs October 15 through December 7. During this time, eligible individuals may enroll in or change Medicare Advantage Plans. Coverage will begin January 1.

Other Enrollment Methods

Fax: 1-844-260-7923
For Phone Applications (please call to speak with a licensed agent)
Phone: 1-844-324-0691 (TTY 711)
Phone: 1-800-MEDICARE (1-800-633-4227)
Hours: 8 am - 8 pm Mon - Fri (Mon - Sun from 10/15/16 to 2/14/17)
Online: Medicare beneficiaries may also enroll in Vibra Health Plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

Note

You must continue to pay your Medicare Part B premium.

Vibra Health Plan is a PPO with a Medicare contract. Enrollment in Vibra Health Plan depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.


Last Updated Nov. 11th, 2016 (H9408_17_49134_Webenroll Approved)

Tell us where you live.

Medicare beneficiaries may also enroll in Vibra Health Plan through the CMS Medicare Online Enrollment Center located at https://www.medicare.gov.

To view your coverage options, enter your zip code and county below.

Your location

We're sorry, but you have either entered an incorrect zip code or you are out of our service area.

Required field

Vibra Health Plan is a PPO with a Medicare contract. Enrollment in Vibra Health Plan depends on contract renewal.

Before you enroll

To make sure you are eligible we'll need a few more pieces of information.

Before your enroll

You must have Medicare Part A and Part B to join a Medicare Advantage Plan.

Generally you are not eligible to enroll in our plan if you have been medically determined to have ESRD. If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, you are eligible to enroll, we will need to contact you to obtain additional information.

Are you new to Medicare?

Are you already entitled to Part A and enrolled in Part B?

Do you have end-stage renal disease ESRD?

If you have had a successful kidney transplant and/or you don't need regular dialysis any more, please mail a note or records from your doctor showing you have had a successful kidney transplant or you don't need dialysis, otherwise we may need to contact you to obtain additional information.

Vibra Health Plan, Inc.

4000 Crums Mill Rd.

Suite 201

Harrisburg, PA 17112
To speak with a licensed agent call 1-844-324-0691 (TTY 711)

8 am - 8 pm Mon - Fri (Mon - Sun from 10/15/16 to 2/14/17)

Previous

Almost there.

Thank you for adding some of your information. You can now download our enrollment application.

We are unable to accept online enrollments at this time. Please check back on October 15, or feel free to download the paper application. Applications should be mailed to:

PO Box 60250,
Harrisburg, PA 17106
Fax: 1-844-260-7923

To speak with a licensed agent, please call 1-844-324-0691 (TTY 711).


Important Information

You may enroll in only one Medicare Advantage Plan at a time.

You may join or leave that plan only at certain times of the year or in special circumstances.

The Annual Election Period occurs October 15 through December 7. During this time, eligible individuals may enroll in or change Medicare Advantage Plans. Coverage will begin January 1.

Other Enrollment Methods

Fax: 1-844-260-7923
For Phone Applications (please call to speak with a licensed agent)
Phone: 1-844-324-0691 (TTY 711)
Phone: 1-800-MEDICARE (1-800-633-4227)
Hours: 8 am - 8 pm Mon - Fri (Mon - Sun from 10/15/16 to 2/14/17)
Online: Medicare beneficiaries may also enroll in Vibra Health Plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

Note

You must continue to pay your Medicare Part B premium.

Vibra Health Plan is a PPO with a Medicare contract. Enrollment in Vibra Health Plan depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.


Last Updated Nov. 11th, 2016 (H9408_17_49134_Webenroll Approved)