Medcore Appeals, Grievances and Exceptions

"Appeals", "grievances" and "exceptions" are different types of complaints you can make.

Filing a Grievance or Appeal

When you have a problem or complaint, which we cannot resolve immediately, you are encouraged to file a grievance or an appeal.

A grievance is a complaint about a problem you observe or experience, including complaints about the quality of services you receive, or regarding other service related issues including office waiting times, physician behavior, adequacy of facilities, or other similar concerns or issues.

An appeal is a complaint about a coverage decision, including a denial of payment for a service you received, or a denial for a requested service you feel you are entitled to as a Medcore HP member. Coverage decisions that may be appealed include a denial for payment for any health care services you received, or a denial of a service you believe should have been arranged for, furnished, or paid for by Medcore HP.

Filing a Grievance

The Member Services Department staff is available to assist you in filing your grievance or appeal. Your doctor can also act on your behalf. A complaint form is available for your convenience, and can be obtained at the Medcore HP office at 2609 E. Hammer Lane Stockton, CA 95210, or you can contact Member Services and a copy will be sent to you, or you download a copy (link here).

You do not have to use the complaint form to file a grievance or appeal. You may call Member Services, send us a letter or fax, or come into our office.

Contact Member Services:

By Telephone:

By Fax:

By Mail:

In Person:

Expedited Appeals

In some situations you are entitled to an expedited appeal. This applies when a delay in decision-making might result in an imminent and serious threat to our health, including but not limited to severe pain, potential loss of life, limb, or major bodily function. Once an expedited appeal has been received, Medcore HP will evaluate your request and medical condition to determine if your appeal qualifies as "expedited". Expedited appeals are processed within 72 hours.

Filing a request for an exception to the Plan's formulary

Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request. You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a brand name drug, you can ask us to cover it as a generic drug instead. This would lower the co-payment amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan's formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

To request an exception you may use the Request For Medicare Prescription Drug Coverage Determination Form available on this website. Once you have completed your portion of the Form, please print this form and provide to your prescribing physician for final completion. Your Physician's office can submit this form via fax (877) 837-5922.

Note: For immediate service your Physicians office can call for a coverage determination to (800) 417-8164 (option 1)

For assistance in filing an appeal, including a Request For Medicare Prescription Drug Coverage Determination Form contact Member Services:

By Telephone:

By Fax:

By Mail:

In Person:

California Department of Managed Health Care

Health plans in California are regulated by the Department of Managed Health Care; a department of the state government. The following paragraph is information from the department about assistance you may be able to receive to assist you.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 800- 320-5688 or (TTY/TDD (800)-258-6810) and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been resolved satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medial necessity or a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical service. The department also has a toll-free telephone number (1-800-HMO-2219) and a TDD line (1-877-688-9891) or the hearing and speech impaired. The department's website has complaint forms, IMR application forms, and instructions on line.

Forms

Request for Medicare Prescription Drug Coverage Determination
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Appointment of Representative
Prescription Drugs

Appeals, Grievances and Exceptions