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Grievance and Appeals Process for Medicare Part C (Medical Services and Benefits)

Grievance, Exceptions, Coverage Determinations and Appeals Procedures for Medicare Part D (Prescription Drug Benefits)

Medicare Complaint Form

Medicare Ombudsman - The Office of the Medicare Ombudsman (OMO) can help you with complaints, grievances and information requests. 

You may also contact Medicare directly through their website, www.medicare.gov, or at 1-800-MEDICARE, 24 hours a day, seven days a week.

What's an Appeal?

An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services or payment for services you already received.

Checking Appeal Status

To check the status of an appeal, or if you questions about the process, call our customer service department at 800-378-5234, Monday through Friday, 8 a.m. - 8 p.m. (TTY 800-947-3529).

Right to Obtain Appeals and Grievances Aggregate Information

As a member of Network Health's Medicare Advantage Plans, you have a right to request the aggregate number of exceptions, grievances and appeals filed with us. To obtain this information, contact a health care concierge at 800-378-5234, Monday through Friday, 8 a.m. - 8 p.m. (TTY 800-947-3529).

Change to Quality Improvement Organization Contact Information

Effective August 1, 2014, KEPRO became the new Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for the Centers for Medicare & Medicaid Services (CMS) in Wisconsin. KEPRO has a group of doctors and other health professionals who are paid by the Federal Government to check on and help improve the quality of care for people with Medicare. KEPRO is an independent organization and is not associated with your plan.

You should contact KEPRO in these situations.

  • You have a complaint about the quality of care you 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.

To contact KEPRO, you can call toll-free 855-408-8557 (TTY 855-843-4776), fax 844-834-7130 or write to the address below. Or, visit https://ww.keproqio.com for additional information.

KEPRO 
5201 W. Kennedy Blvd., Suite 900 
Tampa, FL 33609

To Learn More, See Your 2018 Evidence of Coverage

In addition, for more information, see the chapter of your Evidence of Coverage called What to Do If You Have a Problem or Complaint (Coverage Decisions, Appeals, Complaints). 

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