We take your concerns seriously and consider them opportunities to improve care and service to our enrollees.

Following is an overview of the Community HealthFirst Appeals & Grievances Policy Handbook, or read it in Espanol. If you are a member of our MA Special Needs Plan (014), please read this Appeals and Grievances information for MA Special Needs Plan (014). You will need Adobe Acrobat Reader to view the PDF documents on this website. Download Adobe Acrobat Reader for free.

If you want, you can also contact CMS directly with your concerns by calling them at 1-800-MEDICARE, or through their website at: www.medicare.gov/MedicareComplaintForm/home.aspx

Appeals

An appeal is when you want us to reconsider a decision we have made about what benefits are covered under your plan or what we will pay. For example, you might appeal if you think we:

  • will not approve payment for care you believe should be covered;
  • are stopping payment for care you need; or,
  • have not paid for a particular medical procedure or service you think should be covered.

You can also request a coverage determination on a Part D prescription drug through the appeal process.

If you wish to file an Appeal, it must be done within 60 days of the notice of denial date.  There are two kinds of appeals: standard and expedited (rush).

A standard appeal request must be in writing and sent to:

Community Health Plan of Washington
Attn: Community HealthFirst Appeals
1111 Third Avenue, Suite 400
Seattle, WA 98101

An expedited appeal can be submitted in writing to the address above, or verbally by calling 1-800-942-0247 (TTY Relay: 7-1-1), 8:00 a.m. to 8:00 p.m., 7 days a week.  You should file an expedited appeal if your health or ability to function could be seriously harmed by waiting more than 72 hours (3 calendar days) for a decision.

You can also fax your appeal request to 206-613-8983 or deliver it in person to the address listed above.

Depending on the nature and type of your appeal, we will notify you as follows.

Standard appeals are processed within: 30 calendar days from the date we receive your request, but may be extended to 44 calendar days if additional information is needed. You will receive notice of our decision in writing along with any supporting explanation.

Decisions on standard appeals for Part D prescription drug coverage determination - within 7 calendar days from the date we receive your request.

Decisions on expedited appeals are made within 72 hours of the receipt of the appeal. If we determine that the appeal should be standard instead, we will promptly call you with that decision and follow up with a written notice within 2 calendar days.

Decisions on expedited appeals for Part D prescription drug coverage determination - within 24 hours from the date we receive your request.

Grievances

A grievance is a complaint you make if you have a problem with your health care provider or the service we provide to you. For example, you would file a grievance if you have a concern about things such as:

  • the quality of your care;
  • waiting times for appointments or in the waiting room;
  • your provider's behavior;
  • the ability to reach someone by phone or get the information you need;
  • the cleanliness or condition of your provider's office; or,
  • the courtesy of services we provide you.

There are two kinds of grievance requests: standard and expedited (rush).

A standard grievance request can be submitted verbally by calling 1-800-942-0247 (TTY Relay: 7-1-1), 8:00 a.m. to 8:00 p.m, 7 days a week, or in writing and sent to:

Community Health Plan of Washington
Attn: Community HealthFirst Grievance Coordinator
1111 Third Avenue, Suite 400
Seattle, WA 98101

An expedited grievance can be submitted in writing to the address above, or verbally by calling the number above.  You should file an expedited grievance if your health or ability to function could be seriously harmed by waiting more than 72 hours (3 calendar days) for a decision.

You can also fax your grievance request to: 206-613-8983 or deliver it in person to the address listed above.

Depending on the nature and type of your grievance, we will notify you as follows:

Standard grievance requests are typically decided upon within 30 calendar days from the date we receive your request, but may be extended if additional information is needed. Grievances filed verbally are responded to verbally. Grievances filed in writing and all quality of care grievances are responded to in writing.

Decisions on Part D prescription drug standard grievance requests are made within 30 days.

Decisions on expedited grievance submittals are made within 72 hours (3 calendar days) of the receipt of the request. If we determine that the grievance should be standard instead, we will promptly call you with that decision and follow up with a written notice within 2 calendar days.

Decisions on Part D expedited grievance requests are made within 24 hours.

Status information for Appeals and Grievances

For a status update on Appeals and Grievances call us 8:00 a.m. to 8:00 p.m., 7 days a week at: 1-800-942-0247 (TTY Relay: 7-1-1)

To obtain an aggregate number of Appeals and Grievances filed with Community HealthFirst, please contact our Customer Service at the number above.

You can also learn more about what happened to formal complaints filed with Community HealthFIrst by reading our current Appeals and Grievances Report.

Medicare Beneficiary Ombudsman

The Medicare Beneficiary Ombudsman helps you with complaints, grievances, and information requests. The Medicare Beneficiary Ombudsman makes sure information is available about the following:

  • What you need to know to make health care decisions that are right for you
  • Your rights and protections under Medicare
  • How you can get issues resolved

For more information, visit: http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html.

 

Page Last Updated September 30, 2016