Grievances, Coverage Determinations and Appeals

Potential for contract termination

MetroPlus may not be available for the following contract year because by law, MetroPlus can choose to not renew our contract with CMS or reduce our service area. CMS may also refuse to renew the contract, thus, resulting in a termination or non-renewal.

Grievances

A grievance is a type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. As a member of the MetroPlus, you have the right to file a grievance if you have a complaint about our plan or one of our network pharmacies.
 
If you have a complaint, please contact Member Services. We will try to resolve your complaint over the phone or within 24 hours of receipt of complaint. If you would like a written response to the complaint, we will send you a written response to your phone request. If we are unable to resolve your complaint over the phone, we have a formal complaint process called Member Complaints & Grievances Procedure. The Customer Services Representative will advise you that they are forwarding your complaint to our Complaints Unit for investigation and resolution. You also have the option of filing your complaint in writing by submitting your complaint to:

MetroPlus Health Plan
160 Water Street, 3rd Floor
New York, NY 10038
Medicare Complaints Unit

Appeals

An appeal is something you do if you disagree with a decision to deny a request for health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our Plan doesn't pay for a drug, item, or service you think you should be able to receive.
If you would like to ask us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what your share of the cost will be, you have the right to file an appeal.
 
If you would like to appoint another individual to act as your representative and file an appeal on your behalf, you will need to complete an Appointment of Representative form. The form must be signed by you and the person who you would like to act on your behalf. You must send in or fax 1.212.908.8824 a copy of the signed form.

Coverage Determination

A coverage determination or coverage decision is a decision MetroPlus makes about your benefits and coverage or about the amount we will pay for your medical services or drugs. We make a coverage decision for you whenever you go to a doctor for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.
 
You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal. There may be someone who is already legally authorized to act as your representative under State law. If you want a friend, relative, your doctor or other provider, or other person to be your representative, print out and complete the Appointment of Representative form (English / Español). The form must be signed by you and by the person who you would like to act on your behalf. You must send in or fax 1.212.908.8701 MetroPlus a copy of the signed form.
 
You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision. Either you or your doctor can ask for a coverage decision, however, if you want a fast or expedited decision, you should consider getting your doctor involved.

Appoint of Representative Form (English Español)
Medicare Prescription Drug Coverage Determination Form
Medicare Prescription Drug Coverage Redetermination Form 

For more information, see Section 6 of your plan's Evidence of Coverage.

Exceptions

An exception is a type of coverage determination or coverage decision that, if approved, allows you to get a drug that is not on your plan sponsor's formulary (a formulary exception), or get a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).
 
You or your doctor can ask for an exception if your drug is not on our formulary or you want us to waive coverage restrictions or limits.
To request an exception, please ask your provider to fill out the Medicare Part D Coverage Determination Request form.

Please mail your request to:
CVS Caremark
1300 E. Campbell Road
Richardson, TX 75081
 
CVS Caremark can also be reached at: 1.877.433.7758

Out of Network Coverage Rules

We can get you the care you need. Before you can see a specialist, your doctor must ask MetroPlus for a referral. If you have an emergency and need a specialist right away, your doctor does not have to call for a referral. If you need a specialist right away, because you have an emergency, you doctor does not have to call for a referral. When your doctor calls, they will provide certain information. After all information is received, MetroPlus will decide within 14 business days from the date of request. If your doctor feels that a delay will cause serious harm to your health, your doctor can ask for a fast track review. In that case, we will decide and get back to you within 72 hours.

Other Resources

Medicare Complaint Form
Coverage Determination and Exception Information
Member Reimbursement Form