File A Complaint or Grievance

What is a Medicare grievance?

A grievance is a type of complaint you make if you have a problem that does not involve payment or services by Buckeye.  This includes problems related to quality of care, waiting times, and the customer service you receive.  If your problem is about decisions related to benefits, coverage, or payment, see the section, File An Appeal, below.

Who can file a grievance?

You or your authorized representative can file a grievance with Buckeye.

How do members file a Medicare grievance?

To file a grievance members can fax, write, or call:

Member Services
Toll-free (866) 389-7690 or TTY (800) 750-0750
8 a.m. – 8 p.m., Monday – Sunday
(866) 719-5435 (Fax)

You may file a grievance within 60 calendar days of the date of the circumstance giving rise to the complaint. There is no filing limit for complaints related to quality of care. The 60 day time limit may be extended for good cause. 

In certain cases, you have the right to ask for a “fast grievance,” meaning we will answer your grievance within 24 hours.

We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we deny your grievance, in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you have.

For quality of care problems, you may also complain to the QIO.

You may complain about the quality of care received under Medicare.  You may complain to us using the grievance process, to the Quality Improvement Organization (QIO), or both. If you file with the QIO, we must help the QIO resolve the complaint.

The QIO is a group of doctors and health care experts that review medical care and handle certain types of complaints from patients with Medicare. There is a QIO in each state. The QIO in Ohio is KePro, who is paid by the federal government to check on and help improve the care given to Medicare patients. 

To file a complaint with the QIO, contact KePro by writing them at KePro, Rock Run Center, Suite 100, 5700 Lombardo Center Drive, Seven Hills, Ohio 44131 or by calling (800) 385-5080.

For complaints related to Medicaid-covered services, you may complain to ODJFS.

If you want to file a complaint related to Medicaid-covered services, contact the Ohio Medicaid Consumer Hotline at (800) 324-8680 or TTY (800) 292-3572 Monday – Friday 7 a.m. – 8 p.m. and Saturday 8 a.m. – 5 p.m.

For more information about filing a complaint or grievance, see your Evidence of Coverage complaint information.

Requesting a Service or Benefit

What is a Medicare initial determination?

Unlike a grievance, an initial determination always relates the coverage of Medicare services or payment issues.  With the initial determination, we explain whether we will provide the service (or drug) members are requesting, or pay for the service (or drug) members are requesting.  If we deny a request, members can appeal the decision [link to that section], as explained later.

Who can file an initial determination, or request for services or payment?

An initial determination may be requested by:

• A member
• An authorized representative 
• A prescriber (the individual who prescribed the service or medication to the member)

How do members file a Medicare initial determination, or request for services or payment?

You, your authorized representative, or your physician can file an initial determination by faxing or writing:

Member Services
Advantage by Buckeye Community Health Plan

Toll-free (866) 389-7690 or TTY (800) 750-0750
8 a.m. – 8 p.m., Monday – Sunday
(866) 719-5435 (Fax)

You will need the following information ready when you call:

• Member name and date of birth
• Member ID number
• Name of the medication or service being requested
• Physician’s phone number
• Physician fax number (if available)

If you are submitting the request in writing, please use the appropriate form:

• Part A and B Requests for Services
• Part D Request from a Member or Authorized Representative
• Part D Request from a Provider

The results of the coverage determination will be sent to the member by mail, and the initiator of the request will be contacted by telephone or fax.  If you would like to inquire about the status of a coverage determination please call Member Services toll-free at the number listed on your identification card; providers should call Provider Services at (866) 296-8731, Monday – Friday, 7 a.m. – 7 p.m. (make sure to indicate you all calling about a Medicare client).

For decisions about medical care or services you have not yet received, the coverage determination is made as quickly as your case requires based on your health status, but no later than 14 days for Part A and B services and 72 hours for Part D prescription drugs.

For decisions about the payment for care you have already received, the coverage determination is made within 30 days for Part A and B services and 72 hours for Part D prescriptions drugs.

Members, their authorized representative, or their physician may also ask for an expedited or fast decision if the member or their doctor believe that waiting for a standard decision could seriously harm their health or their ability to function.  To ask for a fast decision, members can call, fax, or write us at the numbers or address listed above.  We must make decisions regarding these requests as fast as your health status requires, but no later than 72 hours for Part A and B services and 24 hours for Part D prescription drugs.

For more information about requesting a service or benefit, see your Evidence of Coverage requesting a service or benefit information.

 File an Appeal

 What is an appeal?

An appeal is a type of complaint you make when you want a reconsideration of a decision that was made regarding a service, or the amount of payment we paid or will pay for a service, or the amount you must pay for a service. 

Who can request an appeal?

An appeal may be requested by:

• A member
• An authorized representative
• In some circumstances, a prescriber or member’s physician who originally requested the service for the member

How do members request an appeal?
Within 60 days of the date on the written notice we sent to tell you our answer to your request for a coverage decision, you can send a signed and written appeal to:

Member Services
Advantage by Buckeye Community Health Plan

Toll-free (866) 389-7690 or TTY (800) 750-0750
8 a.m. – 8 p.m., Monday – Sunday
(866) 719-5435 (Fax)

If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

The results of the appeal decision will be sent to the member by mail, and the initiator of the request will be contacted by telephone or fax.  If you would like to inquire about the status of an appeal, please call Member Services toll-free at the number listed on your identification card; providers should call Provider Services at (866)296-8731, Monday – Friday, 7 a.m. – 7 p.m. (make sure to indicate you all calling about a Medicare client).

For appeals about medical care or services you have not yet received, the appeal decision is made as quickly as your case requires based on your health status, but no later than 30 days for Part A and B services and 7 days for Part D prescription drugs.

For appeals about the payment for care you have already received, the appeal decision is made within 60 days for Part A and B services and 7 days for Part D prescriptions drugs.

Members, their authorized representative, or in some cases their provider may ask for an expedited or fast appeal if the member or their doctor believe that waiting for a standard decision could seriously harm their health or their ability to function.  To ask for a fast appeal, call, fax, or write us at the numbers or address listed above.  We must make appeal decisions regarding these requests as fast as your health status requires, but no later than 72 hours for Part A and B services and Part D prescription drugs.

To request a Medicaid benefit or appeal a decision related to Medicaid services, you may contact ODJFS.

If you want to pursue a coverage decision or appeal related to Medicaid-covered services, contact the Ohio Medicaid Consumer Hotline at (800) 324-8680 or TTY (800) 292-3572) Monday – Friday, 7 a.m. – 8 p.m. and Saturday 8 a.m. – 5 p.m.

For more information about filing an appeal, see your Evidence of Coverage filing an appeals section.

Appointing a Representative – Instructions & Form

People who want to represent a member can be appointed or authorized by the member. A member can authorize anyone (like a relative, friend, advocate, an attorney, or a doctor) to act as his or her representative and file an appeal on his or her behalf. A representative (or surrogate) can also be authorized by the court or act on behalf of the member in accordance with State law to file an appeal for an enrollee. A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney, or a health care proxy, or a person designated under a health care consent statute.

How to authorize a representative:

• The member must sign, date, and complete a representative form.
• The person acting on behalf of the member must sign, date and complete the same form
• View and print the Appointment of Representative Form. 

If a member is incapacitated or legally incompetent a surrogate is not required to submit an Appointment of Representation Form. The surrogate will need to give Buckeye copies of the legal papers supporting his or her status as the member’s authorized representative.

Buckeye requires a copy of the completed and signed Appointment of Representative Form to process an appeal filed by the member’s representative. The form will be valid during the entire appeal process. The Appointment of Representative Form is valid for one year from the date indicated on the form. A member can revoke the authorization at any time.

How to Obtain an Aggregate Number of the Plan’s Grievances, Appeals, and Exceptions

To obtain more information about the plan’s grievances, appeals, and exceptions, please call Member Services at (866) 389-7690 (TTY 800-750-0750), 8 a.m. to 8 p.m., Monday through Sunday.

Ending Your Membership With Buckeye

If you wish to end your membership in our plan, contact Member Services.  Until your membership ends, you must keep getting your Medicare services and/or prescription drug coverage through our Plan.

H0908 MEM010 008
Approved: 11/30/2010
Last Updated December, 2010