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Appeals & grievances

This information will help you with the appeal and grievance process.

  • Grievances (Parts C and D)
  • Organization determinations
  • Appeals (Parts C and D)
What is a complaint? This is also called a grievance.

A complaint, also known as a grievance, is a way of letting us know that you are not happy about your plan experience such as waiting too long in a doctor’s office, cleanliness of the doctor’s office, behavior by the pharmacist at the pharmacy, or the quality of care received from a doctor.

Another way to say “making a complaint” is “filing a grievance.”
Another way to say “using the process for complaints” is “using the process for filing a grievance.”

If you are not satisfied with the plan or our providers you may file a grievance. You need to file your grievance within 60 days of the occurrence. If you have a good reason for being late in filing a grievance, let us know and we will consider whether or not to extend the timeline for filing.


How to file a grievance

File a complaint/grievance by calling Customer Care at 1.855.562.8853. TTY users should call 711. We are open 8:00 a.m. to 8:00 p.m., Monday to Friday. 

  1. Fax the grievance to us at 1.858.636.2256.
  2. Write a letter with your grievance and mail to:
    Sharp Advantage
    Attention: Appeals and Grievance Department
    8520 Tech Way, Ste. 201
    San Diego, CA 92123
If you want someone else to send us a grievance on your behalf, you must send us an Appointment of Representative Form or a legal document showing that you have chosen someone other than yourself to file for you and that this person has your permission to see all information including medical records about the grievance.

If you or your provider has process or status questions about a grievance, please contact us at the telephone numbers listed above.

For information on how to obtain an aggregate number of grievances, appeals and exceptions filed with Sharp Health Plan or if you have a question about a status of an appeal, grievance or exception you requested, please call Customer Care at 1-855-562-8853 (TTY 711).

Medicare grievance form (coming soon)


What happens when you file a grievance?

Grievances are generally responded to no more than 30 calendar days after the date the grievance is received. If more information is needed and the delay is in your best interest or if you ask us for more time, we may take up to 14 more calendar days (44 calendar days in total) to answer your grievance. If this extension is taken, we will notify you or your representative. Grievances filed because we denied your request for a “fast coverage decision” or a “fast appeal” will automatically be considered a “fast” grievance. If you have a “fast” grievance, we will give you an answer within 24 hours. If we don’t agree with part or all of your grievance we will let you know and include reasons for this response.


Submitting a complaint directly to Medicare

You can submit a complaint about Sharp Advantage directly to Medicare. To submit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.

If you want any information about our plan, like the number of appeals and grievances made by members, please call our Customer Care telephone number. We’re here to help.


What is an organization determination?

An organization determination is when Sharp Advantage makes a decision about whether items or services are covered or how much you have to pay for covered items or services. Sharp Advantage’s network provider or facility has also made an organization determination when it provides you with an item or service, or refers you to an out-of-network provider for an item or service. Organization determinations are called “coverage decisions”.

An organization determination is made for the following:

  • Payment for out-of-area renal dialysis services, emergency services, post-stabilization care, or urgently needed services.
  • Payment for any other health services furnished by a provider other than the health plan that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by Sharp Advantage.
  • Sharp Advantage’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by Sharp Advantage.
  • Reduction or premature discontinuation of a previously authorized ongoing course of treatment.
  • Failure of Sharp Advantage to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee.


How to file or send us a request for an organization determination

  1. Providers may call 1.855.820.2112.

    You can call us to request an organization determination. Please call Customer Care at 1.855.820.2112. TTY users should call 711. We are open 8:00 a.m. to 6:00 p.m., Monday to Friday.

  2. Fax the Organization Determination to us at 858.636.2426
  3. Send us an Organization Determination by mail to:

Sharp Advantage
Attention: Customer Care Department
8520 Tech Way, Ste. 201
San Diego, CA 92123

If you want someone else to send us an organization determination on your behalf, you must send us an Appointment of Representative Form or a legal document showing that you have chosen someone other than yourself to file for you and that this person has your permission to see all information including medical records about the organization determination.

If you or your provider has process or status questions about an organization determination, please contact us at the telephone numbers listed above.


What happens when you file an organization determination?

While we review your request for an organization determination, we will use the “standard” timeframe unless the request was submitted for “expedited” review. If more information is needed and the delay is in your best interest or if you ask us for more time, we may take up to 14 more calendar days (44 calendar days in total) to answer your organization determination. If this extension is taken, we will notify you or your representative.

 

Decision type Standard time Expedited time
Medical decisions 14 days Fast 72 hours
Payment decisions 60 days

 

In some cases we might decide a service is not covered or is no longer covered by your plan. If we deny part or all of your request, we will send you a detailed written explanation of the denial and instructions on how to appeal the decision.

If we do not give you our answer within the standard or expedited time, you have the right to appeal. You also have the right to file an appeal if you disagree with our decision.

 


What is an appeal?

An Appeal is a formal way of asking us to reconsider a decision that we have made about benefits or coverage. If you are not happy with the decision made, you can request an appeal. You can appeal decisions about your medical care or prescription drugs.

The appeal must be filed within 60 days of the original decision. If you have a good reason for being late in filing the appeal, let us know and we will consider whether or not to extend the timeline.

If your health requires it, ask us to give you a “fast coverage decision.” A fast coverage decision is called an “expedited determination” (Part C) or an “expedited coverage determination” (Part D). To get a fast coverage decision, you must be asking for coverage for medical care or a drug you have not yet received. You can also get a fast coverage decision if it is determined that using the standard deadlines could cause serious harm to your health or hurt your ability to function.


How to file an appeal

  1. File a standard or expedited (fast) appeal by calling Customer Care at 1-855-820-2112. TTY users should call 711. We are open 8:00 a.m. to 8:00 p.m. Pacific Standard Time, 7 days per week, from October 1 through February 14. After February 14, your call will be handled by our voicemail system on weekends and holidays.
  2. Fax the standard or expedited appeal to us at 1-866-687-0518.
  3. Appeal by mail to:

Sharp Advantage
Attention: Appeal and Grievance Department
8520 Tech Way, Ste. 201
San Diego, CA 92123

If you want someone else to file your appeal on your behalf, you must send us an Appointment of Representative Form or a legal document showing that you have chosen someone other than yourself to file for you and that this person has your permission to see all information including medical records about the Appeal.

If you or your provider has process or status questions about your Appeal, please contact us at the telephone numbers listed above.


What happens when you file an appeal?

We will have a different doctor, other than the one who reviewed your original decision, review your appeal to decide whether or not we should change our original decision. We may ask for additional information from you or your provider. Your appeal will be processed as fast as your health status and circumstances require, but no later than:

 

Part C – Medical (Reconsiderations/Appeals)

Decision type Standard time Expedited time
Medical decisions 14 days Fast 72 hours
Payment decisions (Part C) 60 days

Part D– Prescription Drug (Reconsiderations/Appeals)

Decision type Standard time Expedited time
Medical decisions 14 days Fast 72 hours
Payment decisions (Part D) 7 days


Download the Part D Redetermination (Appeal) Request Form.


 

Sharp Advantage is offered by Sharp Health Plan. Sharp Advantage is an HMO plan with a Medicare contract. Enrollment in Sharp Advantage depends on contract renewal. Read the full disclaimer.

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Page Last Updated: 10/01/2016