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Appeals and Grievances

You can file a grievance if you’re unhappy with our service, plans or providers. You can also appeal a denial of payment, eligibility or other decision.


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: 844.774.5585
Phone: 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: 800.693.6703 
Phone: 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 appeal 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: 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 800.633.4227.

For questions about the complaint process or to file a complaint by phone, you may contact Member Services at 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 844.388.8268 (TTY 711).

Updated October 1, 2018
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