Medicare Advantage general coverage decisions, appeals and grievances.
Your health plan must follow strict rules for how to identify, track, resolve and report all appeals and grievances. The following information applies to benefits provided by your Medicare benefit.
These processes have been approved by Medicare. Each process has a set of rules, procedures, and deadlines that must be followed by us and by you.
We are always available to help you. Even if you have a complaint about our treatment of you, we are obligated to honor your right to complain. Therefore, you should always reach out to customer service for help.
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or prescription drugs.
The sections below provide more information about each of these types of coverage decisions and how to ask Preferred Care Network for a coverage decision.
When a coverage decision involves your medical care, it is called an organization determination.
Some examples of an organization determination are:
You can ask us for an organization determination yourself, or your doctor or someone you have legally appointed to act on your behalf may do it for you. This person would be called your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you. If you want someone other than your doctor, you must complete the Appointment of Representative Form. When we reference “you” on this page, we mean you, your doctor or your appointed representative.
If your health requires a quick response, you can ask us to make a “fast decision,” which is also called an “expedited determination.” More information about standard organization determinations and expedited determinations is available within this section.
Mail: Submit a written request for an organization determination to the address listed below. You may refer to your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care.
Phone: You may call the customer service number on your ID card. You may refer to your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care.
Fax: Fax a written request for an organization determination to the fax number listed below. You may refer to your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care.
Coverage Decisions for Medical Care Part C and B – Contact Information
1-800-407-9069
(TTY - 711) Toll-Free
8 a.m. - 8 p.m. local time 7 Days Oct-Mar, M-F Apr-Sept
Preferred Care Network
Customer Service Department
P.O. Box 30770, Salt Lake City, UT 84130-0770
1-888-950-1170
1-866-480-1086
(TTY - 711) Toll-Free
8 a.m. - 8 p.m. local time 7 Days Oct-Mar, M-F Apr-Sept
Preferred Care Network
Customer Service Department
P.O. Box 30769, Salt Lake City, UT 84130-0769
1-888-950-1169
For a standard organization determination, we will give you an answer as quickly as your health condition requires, but no later than 14 days after receiving your request. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request.
However, for a request for a medical item or service, if we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more calendar days to make our decision. We will let you know if we decide to do this. We cannot take extra time to make a decision if your request is for a Medicare Part B prescription drug.
If you believe we should not take extra days, you can file a “fast” grievance, and we will give you an answer to your grievance within 24 hours. For more information about grievances, see Grievances.
If we do not give you our answer within 14 calendar days (or, if there was an extended review period, by the end of that period), or within 72 hours if your request is for a Part B prescription drug, you have the right to file an appeal. See Appeals for more information.
If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals.
If your request was for us to pay our share of the bill for medical care you already received, and we determine that the care you paid for was not covered or did not follow plan rules, we will send you a letter that says we will not pay for these services and why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals.
If your health requires it, you can ask us for an expedited determination. To get an expedited determination, you must meet two requirements:
You must be asking for coverage for medical care you have not yet received. You cannot ask for an expedited determination if your request is about payment for medical care, you have already received.
Using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If your doctor tells us that your health requires an expedited determination, we will automatically agree to give you an expedited determination.
If you ask for an expedited determination on your own without your doctor’s support, we will decide whether your health requires that we give you an expedited determination. If we decide your medical condition does not meet the requirements for an expedited determination, we will process your request as a standard organization determination and notify you of our decision to process your request as a standard determination by sending you a letter. Our letter will indicate that we will automatically give you an expedited determination if your doctor requests it. You will also be provided with information about your right to file a “fast” grievance about our decision to give you a standard determination instead of an expedited determination. For more information about grievances, see Grievances.
If you meet the requirements for an expedited determination, we will give you an answer as quickly as your health condition requires, but no later than 72 hours after receiving your request. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours.
However, if we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more days to make our decision. We will let you know if we decide to do this.
If you believe we should not take extra days, you can file a “fast” grievance, and we will give you an answer to your grievance within 24 hours. For more information about grievances, see Grievances.
If we do not give you our answer within 72 hours (or, if there was an extended review period, by the end of that period), or within 24 hours if your request is for a Part B prescription drug, you have the right to file an appeal. See Appeals for more information.
If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals.
Coverage decision involves your Part D prescription drugs, it is called a coverage determination.
Some examples of a coverage determination are:
*Please note: If you are requesting an exception, you will also need to provide a supporting statement from your doctor or prescriber that explains the medical reason why you need the exception approved.
You can ask us for an organization determination yourself, or your doctor or someone you have legally appointed to act on your behalf may do it for you. This person would be called your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you. If you want someone other than your doctor, you must complete the Appointment of Representative Form. When we reference “you” on this page, we mean you, your doctor or your appointed representative.
If your health requires a quick response, you can ask us to make a “fast decision,” which is also called an “expedited determination.” More information about standard organization determinations and expedited determinations is available within this section.
Mail: Submit a written request for an organization determination to the address listed below. You may refer to your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care.
Phone: You may call the customer service number on your ID card. You may refer to your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care.
Fax: Fax a written request for an organization determination to the fax number listed below. You may refer to your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care.
Coverage Decisions for Part D Prescription Drugs – Contact Information
1-866-231-7201
(TTY - 711) Toll-Free
8 a.m. - 8 p.m. local time, 7 Days Oct-Mar; M-F Apr-Sep
Preferred Care Network
Part D Coverage Determination
P.O. Box 25183, Santa Ana, CA 92799
1-844-403-1028
1-866-480-1086
(TTY - 711) Toll-Free
8 a.m. - 8 p.m. local time, 7 Days Oct-Mar; M-F Apr-Sept
Preferred Care Network
Part D Coverage Determination
P.O. Box 25183, MS CA120-0368 Santa Ana, CA 92799
1-844-403-1028
For a standard coverage determination about a drug, you have not yet received:
For a standard coverage determination about payment for a drug you have already bought:
If your request is about a drug, you have not yet received and our answer is “YES” to all or part of what you requested, we must provide the coverage we have agreed to provide as quickly as your health condition requires, but no later than 72 hours after we receive your request or doctor’s statement supporting your request.
If your request is about payment for a drug, you have already received and our answer is “YES” to all or part of what you requested, we must send any payment due to you within 14 calendar days after we receive your request.
For any coverage determination request, if our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals.
If your health requires it, you can ask us for an expedited determination. To get an expedited determination, you must meet two requirements:
If your doctor or other prescriber tells us that your health requires an expedited coverage determination, we will automatically agree to give you an expedited determination.
If you ask for an expedited coverage determination on your own without your doctor’s support, we will decide whether your health requires that we give you an expedited determination. If we decide your medical condition does not meet the requirements for an expedited coverage determination, we will process your request as a standard coverage determination and notify you of our decision by sending you a letter. Our letter will indicate that we will automatically give you an expedited coverage determination if your doctor requests it. You will also be provided with information about your right to file a “fast” grievance about our decision to give you a standard coverage determination instead of an expedited coverage determination. For more information about grievances, see Grievances.
If you meet the requirements for an expedited coverage determination, we will give you an answer as quickly as your health condition requires, but no later than 24 hours after receiving your request or your doctor’s supporting statement (if required).
If our answer is “YES” to all or part of what you requested, we will provide the coverage we have agreed to provide as quickly as your health condition requires, but no later than 24 hours after we receive your request or doctor’s statement supporting your request.
If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals .
If you are unhappy with our organization determination for medical care coverage or our coverage determination for prescription drug coverage, you can submit an appeal.
An appeal is a formal way of asking us to review and change our organization determination or coverage determination. You will submit an appeal if you want us to reconsider and change a decision we have made about medical care or prescription drug benefits, or what we will pay for medical care or a prescription drug.
When you submit an appeal, we review the organization determination or coverage determination to see if we followed all the rules properly. Your appeal is handled by different reviewers than those who made the organization determination or coverage determination. When we have completed the review, we give you, our decision.
For information on the total number of grievances, appeals or formulary exceptions submitted to Preferred Care Network, contact us.
An appeal may be filed by any of the following:
For detailed information on the process of please refer to your plan's Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage Document or your plan's member handbook.
You may ask for either a “standard” appeal or a “fast” appeal. More information about standard appeals and fast appeals for medical coverage and prescription drug coverage is available on this page.
You may file an appeal within 60 days (65 days beginning in 2025) calendar days of the date of the notice of the first coverage decision. For example, you may file an appeal for any of the following reasons:
Note: The 60 days (65 days beginning in 2025) limit may be extended for good cause. Include in your written request the reason you could not file within 60 days (65 days beginning in 2025) timeframe. Your first appeal is called a Level 1 Appeal.
An appeal may be filed in writing or by contacting Preferred Care Network Customer Service. To file an appeal in writing, please complete the Medicare plan Appeal and Grievance Form (PDF) and follow the instructions provided.
To start your appeal, you, your doctor or other provider, or your representative must contact us by mail, fax, or phone.
Call Preferred Care Network Customer Service at the telephone number on the back of your UCard or the TTY – 711 number for the hearing impaired. Hours of Operation: 8 a.m.-8 p.m.: 7 Days Oct-Mar; M-F Apr-Sept
Customer Service also has free language interpreter services available for non-English speakers.
Appeals for Medical Care - Part C / B
Standard Appeal:
1-800-407-9069
(TTY - 711) Toll-Free
Expedited Appeal:
1-877-262-9203
(TTY - 711) Toll-Free
Preferred Care Network
Appeals & Grievance Department
P.O. Box 6106,
MS CA120-0360,
Cypress, CA 90630-0016
Expedited Appeal:
1-866-373-1081
Standard Appeal:
1-866-480-1086
(TTY - 711) Toll-Free
Expedited Appeal:
1-855-409-7041
(TTY - 711) Toll-Free
Preferred Care Network
Appeals & Grievance Department
P.O. Box 6106,
MS CA120-0360,
Cypress, CA 90630-0016
Expedited Appeal:
1-866-373-1081
Appeals for Prescription Drugs - Part D
Standard Appeal:
1-800-407-9069
(TTY - 711) Toll-Free
Expedited Appeal:
1-877-262-9532
(TTY - 711) Toll-Free
Preferred Care Network
Appeals & Grievance Department
P.O. Box 6106,
MS CA120-0368
Cypress, CA 90630-0016
Standard Appeal:
1-866-308-6294
Expedited Appeal:
1-866-308-6296
Standard Appeal:
1-866-480-1086
(TTY - 711) Toll-Free
Expedited Appeal:
1-855-409-7041
(TTY - 711) Toll-Free
Preferred Care Network
Appeals & Grievance Department
P.O. Box 6106,
MS CA120-0368
Cypress, CA 90630-0016
Standard Appeal:
1-866-308-6294
Expedited Appeal:
1-866-308-6296
You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made about a service or the amount of payment your Medicare Advantage health plan paid for an item/service or a Part B drug.
You should include:
You may send in supporting medical records, doctors' letters, or other information that explains why your plan should provide the item/service or Part B drug. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.
If you appeal, Preferred Care Network review the decision. If any of the items/services or Part B drugs you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by a reviewer outside of our Medicare Advantage Organization or prescription drug plan. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.
Timing of the appeal answer depends on the type of request.
Type of request | Timing of organization decision |
---|---|
Standard Part C pre-service or benefit | Within thirty (30) calendar days after receipt of your request |
Standard Part B drug request | Within seven (7) calendar days after receipt of your request |
Expedited Part C pre-service or benefit | Within 72 hours after receipt of your request |
Expedited Part B drug request | Within 72 hours after receipt of your request |
Reimbursement requests | Within 60 calendar days (65 calendar days beginning in 2025) after receipt of your request |
Fast Decisions/Expedited Appeals
You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize:
If your Medicare Advantage health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus fourteen (14) calendar days, if an extension is taken, after receiving the request. For Part B drugs, your Medicare Advantage plan will provide a decision as fast as possible, but no later than 24 hours in Time-Sensitive situations with no allowable extensions.
If we do not give you our answer by the deadlines noted above, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal.
If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 30 calendar days if your request is for a medical item or service, or within 7 calendar days if your request is for a Medicare Part B prescription drug.
If you requested us to pay you back for medical care you already received: If the independent review organization decides we should pay, we must send you or the provider the payment within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process after Level 2, we must send the payment you requested to you or to the provider within 60 calendar days (65 calendar days beginning in 2025). We must give you our answer within 60 calendar days (65 calendar days beginning in 2025) after we receive your appeal.
If our answer is “NO” to all or part of what you requested, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal.
If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 72 hours after we receive your appeal.
If our answer is “NO” to part or all of what you requested, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal.
The Independent Review Organization will review your appeal. This organization is hired by Medicare and is not connected with Preferred Care Network and is not a government agency. We send the information about your appeal to the organization. You have the right to provide the organization with additional information to support your appeal.
If you had a standard Level 1 Appeal, you would have a standard Level 2 Appeal.
If you had a fast Level 1 Appeal, you would have a fast Level 2 Appeal.
If the organization’s answer is “YES” to all or part of what you requested for a standard appeal, we must authorize the coverage within 72 hours or provide the service within 14 calendar days after we receive its decision; and if the organization’s answer is “YES” to all or part of what you requested for a fast appeal, we must authorize the coverage within 72 hours after we receive its decision. If the organization’s answer is “YES” to all or part of a standard appeal request for a Medicare Part B prescription drug, we must authorize or provide coverage within 72 hours after we receive its decision; and if the organization’s answer is “YES” to all or part of a fast appeal request for a Medicare Part B prescription drug, we must authorize or provide the coverage within 24 hours after we receive its decision.
If the organization’s answer is “YES” to your request about a payment we denied for medical services, we must send the payment you requested within 30 calendar days to you or the provider.
If the organization’s answer is “NO” to part or all of what you requested, it means it agrees with us that your request or part of your request should not be approved. The organization will send you a letter explaining its decision and that tells you the dollar value that must be in dispute for you to continue with the appeals process. If your case meets these requirements, you decide if you would like to continue the appeals process.
For a standard Level 1 Appeal, we will give you an answer as quickly as your health condition requires but no later than 7 calendar days after we receive your appeal.
If you are requesting that we pay you back for a drug you have already bought, we must give you our answer within 14 calendar days after we receive your request. If we do not give you our answer within 14 calendar days, we are required to send your request to the Independent Review Organization as a Level 2 Appeal.
If you requested coverage for a drug and our answer is “YES”, we must provide the coverage we have agreed to provide as quickly as your health condition requires, but no later than 7 calendar days after we receive your appeal.
If you requested us to pay you back for a drug you already bought and our answer is “YES”, we are required to send you payment within 30 calendar days after we receive your appeal.
If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. This notice will also provide information on how to appeal your decision as a Level 2 Appeal.
If your health requires it, you can ask us for a “fast” appeal. To get a fast appeal, you must meet two requirements:
If your doctor or other prescriber tells us that your health requires a fast appeal, we will automatically agree to give you a fast appeal.
If you ask for a fast appeal on your own without your doctor’s or other prescriber’s support, we will decide whether your health requires that we give you a fast appeal. If we decide your medical condition does not meet the requirements for a fast appeal, we will process your request as a standard appeal and notify you of our decision to process your request as a standard appeal by sending you a letter. Our letter will indicate that we will automatically give you a fast appeal if your doctor or other prescriber requests it. We will also provide you with information about your right to file a “fast” grievance about our decision to give you a standard appeal instead of a fast appeal. For more information about grievances, see Grievances (Complaints).
For a fast Level 1 Appeal, we will give you an answer as quickly as your health condition requires but no later than 72 hours after we receive your appeal. If we do not give you our answer within 72 hours, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal.
If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 72 hours after we receive your appeal.
If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why we said no and how to appeal our decision as a Level 2 Appeal.
What happens with a Level 2 Appeal for Prescription Drugs?
If we say no to your appeal, you then choose whether to accept this decision or continue by submitting another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed. This organization is hired by Medicare and is not connected with Preferred Care Network and is not a government agency.
To file a Level 2 Appeal, you must contact the Independent Review Organization listed in the letter we sent you when we said “NO” to your Level 1 Appeal. This letter also includes instructions on how to file a Level 2 Appeal, including deadlines for contacting the organization. If you do file a Level 2 Appeal, we will send the information we have about your appeal to the organization. You have the right to provide the organization with additional information to support your appeal.
For a standard Level 2 Appeal, the organization must give you an answer within 7 calendar days of when it receives your appeal.
If your health requires it, you may ask the organization for a fast Level 2 Appeal. If the organization agrees to a fast appeal, it must give you an answer within 72 hours of when it receives your appeal.
If we say no to your appeal, you then choose whether to accept this decision or continue by submitting another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed. This organization is hired by Medicare and is not connected with Preferred Care Network and is not a government agency.
To file a Level 2 Appeal, you must contact the Independent Review Organization listed in the letter we sent you when we said “NO” to your Level 1 Appeal. This letter also includes instructions on how to file a Level 2 Appeal, including deadlines for contacting the organization. If you do file a Level 2 Appeal, we will send the information we have about your appeal to the organization. You have the right to provide the organization with additional information to support your appeal.
For a standard Level 2 Appeal, the organization must give you an answer within 7 calendar days of when it receives your appeal.
If your health requires it, you may ask the organization for a fast Level 2 Appeal. If the organization agrees to a fast appeal, it must give you an answer within 72 hours of when it receives your appeal.
If your appeal was for coverage of a drug and the organization’s answer is “YES” to all or part of what you requested, we must provide the drug coverage:
If your appeal was for us to pay you back for a drug you already bought and the organization’s answer is “YES” to all or part of what you requested, we must send payment to you within 30 calendar days after we receive the organization’s decision.
If the organization’s answer is “NO” to part or all of what you requested, it means it agrees with us that your request or part of your request should not be approved. The organization will send you a letter explaining its decision and that tells you the dollar value that must be in dispute for you to continue with the appeals process. If your case meets these requirements, you decide if you would like to continue the appeals process.
A “complaint” is also called a “grievance.” The complaint process is only used for certain types of problems. This includes problems related to quality of care, waiting times, and the customer service. Here are examples of the kinds of problems handled by the complaint process.
For information on the total number of grievances submitted to Preferred Care Networks, contact us.
You may file a grievance within 60 calendar days of the date of the circumstance giving rise to the grievance.
Note: The 60 days limit may be extended for good cause. Include in your written request the reason why you could not file within the 60 days timeframe.
You have the right to request an expedited grievance if you disagree with your Medicare Advantage health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your Medicare Advantage health plan's decision to process your expedited reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.
A grievance may be filed in writing or calling directly to us.
You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.
A grievance may be filed by any of the following:
If you want someone to act for you, who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. You may appoint an individual to act as your representative to file the grievance.
To learn how to name your representative, call Preferred Care Network Member Service.
Filing a grievance with our plan
The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Grievances listed on the back of your member ID card. We will try to resolve your complaint over the phone.
You can call Preferred Care Network Member Service, 8 a.m. - 8 p.m.: 7 Days a week, Oct-Mar, M-F Apr-Sept
Member Service also has free language interpreter services available for non-English speakers.
If you do not wish to call (or called and were not satisfied), you can put your complaint in writing and send it to us. Members also, can file via the member’s portal: Member Sign In
Submit a written request for a grievance to Part C & B:
Standard Complaint:
1-800-407-9069
(TTY - 711) Toll-Free
Expedite Complaint:
1-877-262-9203
(TTY - 711) Toll-Free
Preferred Care Network
Appeals & Grievance Department
P.O. Box 6106,
MS CA120-0360,
Cypress, CA 90630-0016
Expedite Complaint:
1-866-373-1081
Standard Complaint:
1-866-480-1086
(TTY - 711) Toll-Free
Expedited Complaint:
1-855-409-7041
(TTY - 711) Toll-Free
Preferred Care Network
Appeals & Grievance Department
P.O. Box 6106,
MS CA120-0360,
Cypress, CA 90630-0016
Expedite Complaint:
1-866-373-1081
Submit a written request for a grievance to Part D:
Standard Complaint:
1-800-407-9069
(TTY - 711) Toll-Free
Expedited Complaint:
1-877-262-9532
(TTY - 711) Toll-Free
Preferred Care Network
Appeals & Grievance Department
P.O. Box 6106,
MS CA120-0368
Cypress, CA 90630-0016
Standard Complaint:
1-866-308-6294
Expedited Complaint:
1-866-308-6296
Standard Complaint:
1-866-480-1086
(TTY - 711) Toll-Free
Expedited Complaint:
1-855-409-7041
(TTY - 711) Toll-Free
Preferred Care Network
Appeals & Grievance Department
P.O. Box 6106,
MS CA120-0368
Cypress, CA 90630-0016
Standard Complaint:
1-866-308-6294
Expedited Complaint:
1-866-308-6296
If you ask for a written response, file a written grievance, or if your complaint is related to quality of care, we will respond in writing.
If you are filing a grievance because we denied your request for a “fast” decision on an organization determination or coverage determination or a “fast” appeal, we will automatically give you a “fast” grievance. This means we will give you an answer to your grievance within 24 hours.
Whether you call or write, you should contact Customer Service right away. The complaint must be made within 60 calendar days, after you had the problem, you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.
If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we do not agree with some or all your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.
Please refer to your plan’s Appeals and Grievance process found in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.
As a member of our plan, you have the right to get several kind of information from us. This includes
information about the number of appeals made by members and the plans performance rating
including how it has been rated by plan members and how it compares to other Medicare Advantage
health plans. To file a complaint directly to CMS. https://www.medicare.gov/MedicareComplaintForm/home.aspx
For detailed information on the process of filing a grievance or appeal and obtaining a coverage
determination, refer to Chapter 9 of your Evidence of Coverage.