Appeals and Grievances

What is a Grievance?

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 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).

Who may file a grievance?

You or someone you name may file a grievance.  The person you name would be your appointed representative.  You may name a relative, friend, advocate, doctor or anyone else. If you would like to notify us that you have a person to act on your behalf, you would have to submit an Appointment of Representative Form.

You must complete the Appointment of Representative Form and send it by mail or fax to:

First+Plus
PO Box 195080
San Juan, PR 00919-5080
Fax: 787-300-3918

Refer to section “Appointing a Representative below” for a copy of the form.

How to file a Grievance?

There are several ways to file a grievance. You can file a grievance verbally or in writing.

Verbally- by calling our Customer Service Department at 1-888-767-7717 (toll free) Monday through Friday from 8:00 a.m. to 8:00 p.m. TTY users should call 1-877-672-4242.

Mail - by sending your signed written request to:

First+Plus
P.O. Box 195080
San Juan, PR 00919-5080

Fax- by sending your signed written request to 787-300-3918.

This complaint must be submitted within 60 calendar days from the day the event or incident occurred. We may give you more time if you have a good reason for missing the deadline.

When will I receive a response?

For standard grievances, we will have to respond to your complaint in writing within 30 calendar days from the date received. We have 24 hours from the date received, to respond to an expedited 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.

What is an Appeal?

An appeal is a formal way of asking us to review and change a coverage decision we have made. An appeal is also known as a reconsideration or redetermination request, this depends if the service denied is related to Part C or if is related to Part D.

If we make an organization determination related to your Part C benefits and you are not satisfied with this decision, you can “appeal” the decision or request a “reconsideration”.

If we make a coverage determination related to your Part D benefits and you are not satisfied with this decision, you can “appeal” the decision or request a “redetermination”.

Who may file an Appeal?

You, your prescribing physician or someone you name may file an appeal.  The person you name would be your appointed representative.  You may name a relative, friend, advocate, doctor or anyone else. If you would like to notify us that you have a person to act on your behalf, you would have to submit an Appointment of Representative Form.

You must complete the Appointment of Representative Form below and send it by mail or fax to:

First+Plus
P.O. Box 195080
San Juan, PR 00919-5080
Fax: 787-300-3918

Refer to section “Appointing a Representative” below for a copy of the form.

How to file an Appeal?

All appeal requests must be submitted within 60 calendar days from which the initial determination was made. We may give you more time if you have a good reason for missing the deadline.

You can file a Part D appeal verbally or in writing. However to request a Part C Appeal, with the exception of an expedited request, you must send a signed written request. All expedited requests, both Part C and Part D, may be filed verbally.

Verbally – by calling our Customer Service Department at 1-888-767-7717 (toll free) Monday through Friday from 8:00 a.m. to 8:00 p.m. TTY users should call 1-877-672-4242.

Mail – by sending your signed written request to:

First+Plus
P.O. Box 195080
San Juan, PR 00919-5080

Fax- by sending your signed written request to 787-300-3918.

When will I receive a response?

Time frames to respond depend on the type of service that you have requested. For Part C service appeals, we have 30 calendar days to respond in writing and 72 hours for expedited requests. We may extend this 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. For appeals related to claims or reimbursements we have 60 calendar days from the date received to respond in writing, 14 day extensions and expedited requests don’t apply to appeals related to claims or payments.

However, Part D appeals must be processed within 7 calendar days for a standard appeal and 72 hours from the date received to respond to an expedited appeal. All responses will be sent in writing.

There are additional levels of appeal if we deny your request in whole or in part. For more information on appeals and grievances, please refer to your Evidence of Coverage “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 through 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) 2013 Information

We must keep track of all grievances and appeals. You have the right to request a summary of information about the appeals and complaints that other members have filed against our plan in the past. To obtain more information, please contact our Customer Service Department at 1-888-767-7717 Monday through Friday from 8:00 am to 8:00 pm. TTY /TDD users should call 1-877-672-4242.

Process and/or status questions

If you are a member, an appointed representative or physician and have any questions regarding our process or status on grievances, coverage determinations, organization determinations or appeals, you can contact us at 1-888-767-7717 Monday through Friday from 8:00 am to 8:00 pm. TTY /TDD users should call 1-877-672-4242.

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”
Y0031_FP_13_3025_09_I F&U

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

For quality of care problems, you may also complain to the Quality Improvement Organization (QIO)

There is a Quality Improvement Organization for each state. For Puerto Rico, the Quality Improvement Organization is called Quality Improvement Professional Research Organization (QIPRO).

QIPRO has a group of doctors and other health care professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. QIPRO is an independent organization. It is not connected with our plan.

You should contact QIPRO in any of these situations:

• You have a complaint about the quality of care you have received.
• You think coverage for your hospital stay is ending too soon.
• You think coverage for your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.