Appeals and Grievances
A Grievance is any complaint or dispute regarding the timeliness, appropriateness, access to, and/or setting of a provided item. You can file a complaint either in writing or verbally expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. A grievance may also include a complaint that a Part D plan sponsor refused to expedite a coverage determination or re-determination. (This type of complaint does not involve coverage or payment disputes).
If you do not wish to call (or you called and were not satisfied), you can file a formal grievance by sending your request in writing. This complaint must be submitted within 60 calendar days from the day the event or incident occurred. We will have to respond to your complaint within 30 calendar days from the date received in writing. We have 24 hours from the date received in writing, to respond to an expedited grievance and 30 calendar days for a standard grievance.
We may extend the time frame by up to 14 calendar days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.
An appeal is a formal way of asking us to review and change a coverage decision we have made. If we make a coverage decision related to your Part D benefits and you are not satisfied with this decision, you can “appeal” the decision.
The appeal must be submitted within 60 calendar days from which the initial determination was made. We have 72 hours from the date received in writing, to respond to an expedited appeal and 7 calendar days for a standard appeal.
We must keep track of all grievances and appeals in order to report data to CMS and to our members, upon request. To obtain more information, please contact our Customer Service Department at 1-888-767-7717 Monday thru Friday from 8:00 am to 8:00 pm. TTY /TDD users should call 1-877-672-4242.
Submitting a Grievance or an Appeal
Original documents relating to a Grievance or Appeal should be sent by fax to 787-300-3918 or by mail to the following address:
First+Plus
P.O. Box 195080
San Juan, PR 00919-5080
If we deny your request in whole or in part, you will receive a written decision explaining the denial reasons, and information on any dispute resolution options you may have.
Remember, Grievances and Appeals related to your Prescription drug coverage can also be filed verbally by calling our Customer Services Department.
For more information on appeals and grievances, please refer to your Evidence of Coverage Chapter 9 “What to do you if you have a problem or complaint (Coverage decisions, Appeals and Complaints)” or call our Customer Service Department at 1-888-767-7717 Monday thru Friday from 8:00 am to 8:00 pm. TTY /TDD users should call 1-877-672-4242.
Click here for Evidence of Coverage (EOC) Information
Appointing a Representative
You or someone you appoint as an authorized representative may file a grievance or appeal. You can appoint a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Or, you may already have someone authorized under Commonwealth 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.
Click here to download “Appointment of Representative Form”
The form is also available on the following link, which will redirect you to the CMS website.
http://www.cms.gov/cmsforms/downloads/cms1696.pdf