At VNS CHOICE, our goal is to deliver the medical services you need with courtesy and respect. If you are not satisfied with the care and services you receive from our staff and our providers, we hope you will let us know.

As a member of VNS CHOICE MLTC or VNS CHOICE MLTC Plus (HMO), you have rights that protect you and information about you. These are explained in detail in your Member Handbook (also called the Evidence of Coverage), but they include the right to be treated with dignity, respect and fairness; the right to privacy of your medical records and personal health information; to receive covered services in a timely manner; and to be informed of and participate in decisions about your health care.

You also have the right to make a complaint if you have concerns or problems related to your care, or if you have a complaint with VNS CHOICE or one of our plan providers. You can file an appeal or a grievance if you want us to reconsider or change a decision we have made about the services or benefits we will cover for you.

Filing an Appeal

An appeal is the type of complaint you make when you want us to reconsider or change a decision. For example, you could file an appeal if:

• We refuse to cover or pay for a service you think we should cover.
• We or one of our providers refuse to give you a service you think should be covered.
• We or one of our plan providers reduces or cuts back on a service you have been receiving.
• You think we are stopping your coverage for a service too soon.

FILING A PART D EXCEPTION

If a drug is not covered in the way you would like it to be covered, you can ask VNS CHOICE to make an "exception."  An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.  Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:

• Covering a Part D drug for you that is not our our plan's List of Covered Drugs (Formulary).
• Removing a restriction on the plan's coverage for a covered drug.
• Changing coverage of a drug to a lower cost-sharing tier. 

If you or your doctor believe you should take a prescription that is not on the VNS CHOICE formulary, you may file an appeal called an exception using this form.

Filing a Grievance

A grievance is the type of complaint you make if you have another sort of problem with VNS CHOICE or one of our providers. For example, you could file a grievance if:

• You are having a problem with the quality of your care.
• You are unable to reach someone by phone or get the information you need.
• You have trouble scheduling appointments in a timely manner.
• You have a problem with your doctor’s office, whether that is its condition or cleanliness, or you are kept too long in the waiting room.

For more information, see Common Questions about Filing an Appeal or Grievance.

Note: In MLTC Plus, there are additional ways that you can file a grievance or appeal if the service you are dissatisfied with is one of your Medicaid benefits. Please see your Member Handbook/ Evidence of Coverage for more information.