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Grievance and Appeals

The following information explains the coverage decisions, grievance and appeals, and discrimination complaint processes for AlohaCare Advantage Plus (HMO SNP).

What do I do if I have a problem or concern?
There are four types of processes for handling problems and concerns:
• Coverage Decisions
• Appeals
• Grievances
• Discrimination complaints


What is a Coverage Decision and when do I use it?
A coverage decision is the initial decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We are making a coverage decision anytime we decide what is covered for you and how much we will pay. If you are having problems getting medical care, a service you requested, or payment (including the amount you have already paid) for medical care or services you have already received, then you can resolve the problem through a coverage decision. If your health requires a quick response, you should ask us to make a "fast decision." If we say no, you have the right to ask us to reconsider - and perhaps change - this decision by making an appeal.

To request a Coverage Decision or to ask process or status questions you, your doctor, or your representative may:
  • Call 973-6395 or toll free at 1-866-973-6395
  • TTY/TDD: 1-877-447-5990
  • Fax: 1-800-830-7222
  • Write: AlohaCare Advantage Plus
    Attn: Grievance Coordinator
    1357 Kapiolani Blvd, Suite 1250
    Honolulu, HI 96814

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, there are additional levels of appeal outside our plan. If we deny your appeal, we will inform you about pursuing your appeal further. Also, these additional levels are explained in your Evidence of Coverage in Chapter 9 (“What to do if you have a problem or complaint (coverage decisions, appeals, complaints)”).

To file an appeal or to ask process or status questions you or your representative may:
  • Call 973-6395 or toll free at 1-866-973-6395
  • TTY/TDD: 1-877-447-5990
  • Fax: 1-800-830-7222
  • Write: AlohaCare Advantage Plus
    Attn: Grievance Coordinator
    1357 Kapiolani Blvd, Suite 1250
    Honolulu, HI 96814

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. Examples of grievances include:
  • The customer service you receive
  • Waiting too long on the phone, waiting room, in the exam room or when getting a prescription
  • The length of time required to fill a prescription or the accuracy of filling a prescription
  • The quality of care you received from a provider or facility

Grievances must be filed within 60 days of the event or incident. You may send a complaint to us in writing or by calling Member Services. If you wish to appoint someone to act on your behalf, you must complete an Appointment of Representative form and send it to us with your grievance.

We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.

You may request an expedited grievance if you disagree with our decision to:
  • Not grant you an expedited appeal.
  • Not grant you an expedited determination.
  • Extend the standard review period of an initial decision or appeal.

We will promptly acknowledge that we received your expedited or "fast grievance" within 24 hours. A resolution to your grievance will be accomplished in the timeliest manner but no more than 72 hours from the time of our receipt.

If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.

To file a grievance or to ask process or status questions you or your representative may:
  • Call 973-6395 or toll free at 1-866-973-6395
  • TTY/TDD: 1-877-447-5990
  • Fax: 1-800-830-7222
  • Write: AlohaCare Advantage Plus
    Attn: Grievance Coordinator
    1357 Kapiolani Blvd, Suite 1250
    Honolulu, HI 96814

You may contact us if you would like information on the number of grievances, appeals, and exceptions you have filed with us.


Important Forms
Here are the important forms that will help you in the coverage decision, appeal and grievance process.

Quality Review Organizations
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.
  • For Hawaii, the Quality Improvement Organization is called Livanta.
  • Call: 1-877-588-1123
  • TTY/TDD: 1-855-887-6668
  • Mailing Address: Livanta, LLC
    9090 Junction Drive, Suite 10
    Annapolis Junction, MD 20701

Medicare Complaint Form
If you have complaints or concerns about AlohaCare Advantage Plus and would like to contact Medicare directly please use the following information. By clicking on the link, you will be leaving the AlohaCare website.

The Medicare Beneficiary Ombudsman
The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances and information requests. By clicking on the link, you will be leaving the AlohaCare website. 

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

How do I find out more information about AlohaCare's coverage decision, appeals, and grievances?
Please refer to chapter nine of AlohaCare Advantage Plus' Evidence of Coverage (EOC) (“What to do if you have a problem or complaint (coverage decisions, appeals, complaints)”) for more information regarding coverage decisions, appeals, and grievances processes.

You may contact Member Services with any questions or concerns including how to obtain information regarding the aggregate number of grievances, appeals, and exceptions filed with AlohaCare’s Medicare Advantage Plan.
Nondiscrimination
It is AlohaCare’s policy not to discriminate on the basis of race, color, national origin, sex, age or disability. AlohaCare has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. 18116) and its implementing regulations at 45 CFR part 92, issued by the U.S. Department of Health and Human Services. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities. Section 1557 and its implementing regulations may be examined by contacting AlohaCare’s Compliance Officer, who has been designated to coordinate AlohaCare’s efforts to comply with Section 1557.
 
AlohaCare
Attn: Compliance Officer
1357 Kapiolani Blvd., Suite 1250
Honolulu, HI 96814
 
Phone: 973-0712
Toll-free: 1-877-973-0712
TTY: 1-877-447-5990
 
Any person who believes someone has been subjected to discrimination on the basis of race, color, national origin, sex, age or disability may file a grievance under this procedure. It is against the law for AlohaCare to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance.
 
Procedure:
  • Grievances must be submitted to the Section 1557 Coordinator within (60 days) of the date the person filing the grievance becomes aware of the alleged discriminatory action.
  • A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.
  • The Section 1557 Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it will be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 1557 Coordinator will maintain AlohaCare’s files and records relating to such grievances. To the extent possible, and in accordance with applicable law, the Section 1557 Coordinator will take appropriate steps to preserve the confidentiality of files and records relating to grievances and will share them only with those who have a need to know.
  • The Section 1557 Coordinator will issue a written decision on the grievance, based on a preponderance of the evidence, no later than 30 days after its filing, including a notice to the complainant of their right to pursue further administrative or legal remedies.
  • The person filing the grievance may appeal the decision of the Section 1557 Coordinator by writing to AlohaCare’s Chief Executive Officer within 15 days of receiving the Section 1557 Coordinator's decision. The Chief Executive Officer shall issue a written decision in response to the appeal no later than 30 days after its filing.

The availability and use of this grievance procedure does not prevent a person from pursuing other legal or administrative remedies, including filing a complaint of discrimination on the basis of race, color, national origin, sex, age or disability in court or with the U.S. Department of Health and Human Services, Office for Civil Rights. A person can file a complaint of discrimination electronically through the Office for Civil Rights Complaint Portal, which is available at:
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail at:
U.S. Department of Health and Human Services,
200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201.

Complaint forms are available at:
http://www.hhs.gov/ocr/office/file/index.html. Such complaints must be filed within 180 days of the date of the alleged discrimination.
AlohaCare will make appropriate arrangements to ensure that individuals with disabilities and individuals with limited English proficiency are provided auxiliary aids and services or language assistance services, respectively, if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing qualified interpreters, providing taped cassettes of material for individuals with low vision, or assuring a barrier-free location for the proceedings.


H5969_400619_17 Approved

Last updated 11/16/2016. Please contact AlohaCare for more information.