Gateway Health Plan Medicare AssuredSM
Part D (Prescription Drug) Grievances and Appeals
GRIEVANCES
A grievance is any complaint or dispute, other than one that involves a coverage determination, expressing dissatisfaction with any aspect of the operations, activities or behavior of Gateway Health Plan® ("Gateway") regardless of whether corrective action is requested.
A Grievance may be filed by phone or in writing and may express dissatisfaction with the operations, activities or behavior of Gateway or with the quality of care or service received from a Gateway Health Plan Medicare AssuredSM provider. Grievances must be filed no later than sixty (60) calendar days after the event or incident that precipitates the Grievance. Gateway reviews all grievances as quickly as a member's health condition requires, but no later than thirty (30) days from when the Grievance is received.
To file a grievance, you may use this form: Member Grievance Form
If you have any questions or would like to file a grievance, you may call Gateway Health Plan Medicare AssuredSM Member Services 8:00 a.m. to 8:00 p.m. seven (7) days a week. Members in Pennsylvania should call 1-800-685-5209. Members in Ohio should call 1-888-447-4505. TTY users should call 1-800-654-5988.
APPEALS
An appeal refers to any of the procedures that deal with the review of adverse coverage determinations made by Gateway regarding the benefits under a Part D plan that a member believes that he or she is entitled to receive. An appeal can also be filed to dispute any amounts a member must pay for drug coverage. Except when the time filing time frame is extended, the request must be filed within sixty (60) calendar days from the date of the notice of the Coverage Determination. These procedures are called Redeterminations by Gateway and Reconsiderations at the Independent Review Entity (IRE), Administrative Law Judge (ALJ), Medicare Appeals Council (MAC) or judicial review levels of review.
If Gateway denies a request for coverage of a Part D drug, in full or in part, the member or authorized representative may ask Gateway to review the denial by requesting a Redetermination. A request for a Redetermination can be made by phone or in writing to Gateway. Gateway will review a request for Standard Redetermination as quickly as the member's health condition requires, but no later than seven (7) calendar days from the date the request was received. If the Redetermination decision is not entirely in the member's favor, the decision notice will explain the member's right to request the review by the Independent Review Entity (IRE). The IRE will review the facts of the case and decide if Gateway's decision was correct. There are other appeal options that may be available after the IRE level of review, depending on the value of the drug in dispute.
To file a redetermination, you may use this form: Standard Redetermination Form
EXPEDITED APPEALS
If applying timeframe of the Standard Redetermination process would jeopardize the member's health, life or ability to regain maximum function, an Expedited (fast) Redetermination may be requested. A request for Expedited Redetermination can be made by phone or in writing to Gateway. If the member's physician does not provide a statement (either verbally or in writing) supporting the need for an Expedited Redetermination, a Gateway Medical Director will review the case to decide if an Expedited Redetermination is required. If the request for an Expedited Redetermination is granted, Gateway will notify the member and prescribing physician of the decision within seventy-two (72) hours of receiving the request. If there is no supporting statement from the physician, and the Medical Director decides that an Expedited Redetermination is not needed, the request will be reviewed under the Standard Redetermination process.
Refer to Section 10 of the Evidence of Coverage for further details on Part D Appeals and Grievance procedures.
If you have any questions or would like to file a Redetermination, you may call Gateway Health Plan Medicare AssuredSM Member Services 8:00 a.m. to 8:00 p.m. seven (7) days a week. Members in Pennsylvania should call 1-800-685-5209. Members in Ohio should call 1-888-447-4505. TTY users should call 1-800-654-5988.
Part C (Medical Services) Grievances and Appeals
GRIEVANCES
A grievance is any complaint, other than one that involves a request for an organization determination expressing dissatisfaction with any aspect of the operations, activities or behavior of Gateway, regardless of whether corrective action is requested.
A Grievance may be filed by phone or in writing and may express dissatisfaction with the operations, activities or behavior of Gateway or with the quality of care or service received from a Gateway provider. Grievances must be filed no later than sixty (60) calendar days after the event or incident that precipitates the Grievance. Gateway reviews all grievances as quickly as a member's health condition requires, but no later than thirty (30) calendar days from when the Grievance is received.
To file a grievance, you may use this form: Member Grievance Form
If you have any questions or would like to file a grievance, you may call Gateway Health Plan Medicare AssuredSM Member Services 8:00 a.m. to 8:00 p.m. seven (7) days a week. Members in Pennsylvania should call 1-800-685-5209. Members in Ohio should call 1-888-447-4505. TTY users should call 1-800-654-5988.
APPEALS
If Gateway denies all or part of a request for a service or payment of a service, a member or authorized representative may ask us to reconsider our decision. This is called an appeal or a request for Reconsideration.
If Gateway denies a request for coverage of a medical service, in full or in part, the member or authorized representative may ask Gateway to review the denial by requesting a Reconsideration. A request for a Reconsideration can be made by phone or in writing to Gateway. Except in the case of an extension of the filing time frame, the request for reconsideration must be filed within sixty (60) calendar days from the date of the notice of the organization determination. Gateway will review a request for Standard Reconsiderations as quickly as the member's health condition requires, but no later than thirty (30) calendar days from the date the request was received. If the Reconsideration is a request for payment of a service that has already been rendered, Gateway must resolve the matter within sixty (60) calendar days of receiving the request.
If the Reconsideration decision is not entirely in the member's favor, Gateway will automatically forward the case file to the Independent Review Entity (IRE). The IRE will review the facts of the case and decide if Gateway's decision was correct. There are other appeal options that may be available after the IRE level of review, depending on the value of the services in dispute. Please refer to Section 9 of the Evidence of Coverage for further details.
To file a reconsideration, you may use this form: Standard Reconsideration Form
EXPEDITED APPEALS
If applying timeframe of the Standard Reconsideration process would jeopardize the member's health, life or ability to regain maximum function, an Expedited (fast) Reconsideration may be requested. A request for Expedited Reconsideration can be made by phone or in writing to Gateway. If the member's physician does not provide a statement (either verbally or in writing) supporting the need for an Expedited Reconsideration, a Gateway Medical Director will review the case to decide if an Expedited Reconsideration is required. If the request for an Expedited Reconsideration is granted, Gateway will notify the member and prescribing physician of the decision within seventy-two (72) hours of receiving the request. If there is no supporting statement from the physician, and the Medical Director decides that an Expedited Reconsideration is not needed, the request will be reviewed under the Standard Reconsideration process.
Refer to Section 9 of the Evidence of Coverage for further details on Part C Appeals and Grievance procedures.
If you have any questions or would like to file a Reconsideration, you may call Gateway Health Plan Medicare AssuredSM Member Services 8:00 a.m. to 8:00 p.m. seven (7) days a week. Members in Pennsylvania should call 1-800-685-5209. Members in Ohio should call 1-888-447-4505. TTY users should call 1-800-654-5988.
APPOINTED REPRESENTATIVES
Members may name a relative, friend, advocate, doctor or someone else to act on his or her behalf. This process is called Appointing a Representative. Other persons may already be authorized under state law to act on a member's behalf. In order to appoint another individual to act on a member's behalf, both the member and the designated individual must sign and date a statement that gives this person legal permission to act as an Appointed Representative.
To appoint a Representative, you may use this form: Appointment of Representative Form
To Contact Us
Written requests for Reconsideration, Redetermination, and Grievances can be sent to this address by mail:
Gateway Health Plan®
Attention: Medicare Complaints Administrator
US Steel Building, Floor 41
600 Grant Street
Pittsburgh, PA 15219-2704
To fax your request: 412-255-4503
To make your request by telephone:
You may call Gateway Health Plan Medicare AssuredSM Member Services 8:00 a.m. to 8:00 p.m. seven (7) days a week. Members in Pennsylvania should call 1-800-685-5209. Members in Ohio should call 1-888-447-4505. TTY users should call 1-800-654-5988.
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