Grievances

What is a grievance?

A grievance is a complaint. It does not involve problems related to:

• Approving or paying for Medicare Part C and Medicare Part D drugs
• Medical care or services
• Having to leave the hospital too soon
• Skilled nursing facility (SNF), home health agency (HHA), or comprehensive rehabilitation facility (CORF) services ending too soon

What types of problems would lead you to file a grievance?

• You have problems with the service you get from Member Services.
• You feel that you are being encouraged to leave (disenroll from) the plan.
• You do not agree with our decision not to give you a "fast" decision or a "fast" appeal.
• We don't give you a decision within the required time frame.
• We don't give you required notices.
• You believe our notices and other written materials are hard to understand.
• You feel that you wait too long for prescriptions to be filled.
• You experience rude behavior by network pharmacists, physicians, or providers. This includes staff in pharmacies, physician offices, or hospitals.
• We fail to give your case to the independent review entity. You do not get a decision on time because of this.
• You do not feel you got the best medical care or services you could get. This includes care during a hospital stay.
• You feel that you wait on the phone, in the waiting room, or in the exam room too long.
• You have a problem getting an appointment when you need it. You wait too long for them.
• The doctor's offices, clinics, or hospitals are not clean or in good condition.
• You were denied an expedited review for your prior authorization or appeal request. This is the only complaint that will be considered expedited and resolved within 24 hours of receipt.

For process or status questions, or to obtain a complete number of AmeriHealth Caritas VIP Care Plus grievances, appeals, and exceptions, please call Member Services at 1-888-667-0318 (TTY 711), 8 a.m. to 8 p.m., seven days a week.

For help with complaints, grievances, and information requests, you can also call the Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (TTY 1-877-486-2048). Or go to the Medicare website and fill out a Medicare Complaint Form. (Please noteby clicking on this link you will be leaving the AmeriHealth Caritas VIP Care Plus website.)