Common Questions about Filing an Appeal or Grievance
Following are frequently asked questions about filing an appeal or grievance.
What is the difference between a "standard" and a "fast" or "expedited" appeal for Medical Care?
What if a member wants to appeal a discharge from Facility Based Care?
How Do I File a Grievance or Appeal?
What rights and responsibilities do members have upon disenrollment from VNS CHOICE Medicare?
What is the difference between a "standard" and a "fast" or "expedited" appeal for Medical Care?
A decision about whether we will cover medical care can be a "standard decision" that is made within the standard time frame (typically within 14 days; see below), or it can be a "fast decision" that is made more quickly (typically within 72 hours; see below). A fast decision is sometimes called a 72-hour decision or an "expedited organization determination."
You can ask for a fast decision only if you or any doctor believes that waiting for a standard decision could seriously harm your health or your ability to function. (Fast decisions apply only to requests for medical care. You cannot get a fast decision on requests for payment for care you have already received.)
Members may also request an appeal for any coverage determination made by VNS CHOICE Medicare. (View our Medical Coverage Determination Form.) When VNS CHOICE Medicare makes a coverage determination, we are deciding whether to provide or pay for covered medical services or prescription drugs and what your share of the cost will be. Members have the right to file an appeal if they would like VNS CHOICE Medicare to reconsider and change a decision made concerning medical services, prescription drug benefits, or the share of the costs that the member is responsible for paying.
What if a member wants to appeal a discharge from Facility Based Care?
A Member has the right, by law, to ask for a review of a discharge date from the Hospital, SNF, HHA, or CORF. Members must contact the Quality Improvement Organization (QIO) for review. If a Member believes he or she is being discharged too soon, he or she must fill out a Notice of Discharge & Medicare Appeal Right
This notice will tell you:
- Why you are being discharged,
- The date that we will stop covering your hospital stay (stop paying our share of your hospital costs),
- What you can do if you think you are being discharged too soon,
- Who to contact for help.
If a Member does not ask the QIO for a "fast appeal" by the deadline (no later than noon on the day before the date the members' Medicare coverage ends), the Member may ask VNS CHOICE Medicare for a "fast appeal" of their discharge.
For more information on member appeal and grievance rights, please refer to the Member Handbook (Evidence of Coverage) for Option 1, Option 2, or MLTC Plus, or the Summary of Benefits for Option 1, Option 2, or MLTC Plus, or contact us.
How Do I File a Grievance or Appeal?
To file a grievance or request an appeal, please:
- Call member services at 1-866-783-1444 (for TTY, please call 1-888-844-5530)
- Send a fax to: 1-866-791-2213
Representatives are available Monday through Friday, 8:00 AM to 8:00 PM and weekends and holidays from 8:00 AM to 8:00 PM.
Members may also mail appeals to:
VNS CHOICE Medicare
Attn: Appeals and Grievances Coordinator
1250 Broadway, 11th Floor
New York, New York 10001
If you are not satisfied with the outcome of your appeal, you will then have the right to an external appeal from an organization or judge not affiliated with VNS CHOICE Medicare. Please refer to the Member Handbook (Evidence of Coverage) for Option 1, Option 2, or MLTC Plus, or the Summary of Benefits for Option 1, Option 2, or MLTC Plus, for more information about how to file an external appeal, or contact us.
If you would like to appoint another individual to act as your representative and file an appeal on your behalf, you will need to send us your request in writing. You must also complete an Authorization for the Release of Health Information form, in order for VNS CHOICE Medicare to share confidential information about you and your health records.
To appoint a representative to act on your behalf, please use the Appointment of Representative form (CMS-1696).
How can Members obtain an aggregate number of grievances, appeals and exceptions filed with the plan?
To obtain an aggregate number of grievances, appeals and exceptions filed with the plan, please call us at 1-866-783-1444 or reach us by mail at:
VNS CHOICE Medicare
Attn: Appeals and Grievances Coordinator
1250 Broadway, 11th Floor
New York, New York 10001
For more information on appeals and grievances, please see the section above.
What rights and responsibilities do members have upon disenrollment from VNS CHOICE Medicare?
"Disenrollment" from VNS CHOICE Medicare means ending your membership in VNS CHOICE Medicare. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice):
- You might leave VNS CHOICE Medicare because you have decided that you want to leave. You can do this at any time for any reason.
- There are also a few situations where you would be required to leave. For example, you would have to leave VNS CHOICE Medicare if you move permanently out of our geographic service area or if VNS CHOICE Medicare leaves the Medicare program. We are not allowed to ask you to leave the plan because of your health.
To disenroll, you may:
- Call Member Services at 1-866-783-1444. Representatives are available Monday through Friday, 8:00 AM to 8:00 PM, and weekends and holidays from 8:00 AM to 8:00 PM, or
- Call 1-800-Medicare, or
- Mail your written disenrollment request to:
VNS CHOICE Medicare
PO Box 4497
Scranton, PA 18505
For more information on plan premiums, please refer to the Member Handbook (Evidence of Coverage) for Option 1, Option 2, or MLTC Plus, or the Summary of Benefits for Option 1, Option 2, or MLTC Plus, or contact us.
