How to File an Appeal or Grievance

Your satisfaction and health are important to us. We will work with you to try to find a solution to your issues. For any issue with Kalos Health Gold Plus, please call Member Services first.

You have rights as a member of this plan and as someone who is getting Medicare. We will treat you with respect and take your concerns seriously. If you would like to obtain a report of the appeals, grievance, and exceptions filed with the plan, you may contact member services and request that information.

Appeal and Grievance information is contained within the Evidence of Coverage (H3227_001_EOC_092017_Accepted.pdf). Click the link and review that material. If you need personal assistance with any issue, please contact Member Services. A representative will be glad to assist.

Coverage decisions about your medical care

A coverage decision is a decision we make about what services or items we will cover for you. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist.

To contact Kalos Health to ask for a coverage decision, call, write, fax, or ask your representative or doctor to ask us for a decision.

CALL

1-800-399-1954

8 a.m.- 5 p.m.

Calls to this number are free.

TTY (TTY 711)
FAX 1-716-731-2013
WRITE

Kalos Health

Medicare Prior Authorization Department

2424 Niagara Falls Blvd.

Niagara Falls, NY 14304

For more information about coverage decisions, see your 2018 Evidence of Coverage (H3227_001_EOC_092017_Accepted.pdf). (You can find the information in Chapter 9.)

Coverage decisions about your Part D prescription drugs

When Kalos Health makes a coverage determination, we are making a decision about whether or not to provide or pay for a Part D prescription drug.

To ask for a coverage decision, call, write, fax, or ask your representative or doctor to ask us for a decision.

CALL

1-844-550-6817 (TTY 711)

Calls to this number are free.

FAX 1-877-503-7321
WRITE

EnvisionRxOptions

 

2181 E. Aurora Rd., Suite 201Twinsburg, OH 44087Attn: Clinical Appeals

WEBSITE You can request a Part D coverage determination using our online form. You can also get this form on the CMS website. (Please note – clicking this link takes you away from the Kalos Health website.)

For more information about Part D coverage decisions, see 2018 Evidence of Coverage (H3227_001_EOC_092017_Accepted.pdf). (You can find the information in Chapter 9.)

Grievance and Appeals

As a member, you or your authorized representative may file and organization determination, grievance and/or appeal within 60 days after you receive an unfavorable notice.

An appeal is a formal way of asking us to review our coverage decision. For example, we might decide that a service or drug that you want is not covered or is not medically necessary for you. If you disagree with our decision, you can ask Kalos Health to review our decision by asking us for a Level 1 Appeal (sometimes called an “internal appeal” or “plan appeal”). You can ask to see the medical records and other documents we used to make our decision any time before or during the appeal. At no cost to you, you can also ask for a copy of the guidelines we used to make our decision.

If you are appealing because Kalos Health plans to reduce or stop a service you were already getting, you have a right to keep getting that service from Kalos Health during your appeal. If you want the service to continue, you must ask for an appeal. For more information about appeals, see your 2018 Evidence of Coverage (H3227_001_EOC_092017_Accepted.pdf). (You can find the information in Chapter 9.)

There are two kinds of Level 1 Appeals

  • Standard Appeal – Kalos Health must give you a written decision on a non-drug standard appeal within 30 days after we get your appeal. Our decision might take longer if you ask for an extension, or if we need more information about your case. We will tell you if we are taking extra time and will explain why more time is needed.
  • Fast (Expedited) Appeal – A member, or any physician may request a fast appeal if you or your health care provider believe your health, life or ability to regain maximum function may be put at risk by waiting up to 30 days for a decision. Kalos Health must give you a decision on a fast (expedited) appeal within 72 hours after we receive your appeal request. We will automatically give you a fast appeal if your health care provider asks for one for you or supports your request.  If you ask for a fast appeal without support from your health care provider, we will decide if your health requires a fast appeal. If Kalos Health denies a request for an expedited reconsideration, it must automatically transfer the request to the standard reconsideration process and then make its determination as expeditiously as the member’s health condition requires, but no later than within 30 calendar days from the date the Medicare health plan received the request for expedited reconsideration.

    How to make a Level 1 Appeal

    You or your authorized representative must ask for a Level 1 Appeal within 60 calendar days of getting an unfavorable written notice. When you make your standard or fast appeal, you should give us the following information:

    • Your name, Address, and Telephone Number
    • Member number
    • Primary language (need for interpreter)
    • Reason for appealing, the dates of the incident(s), the parties involved, and any evidence you want us to review, such as medical records, health care providers’ letters, or other information that explains why you need the item or service. Call your health care provider if you need this information

To ask for an appeal, call, write, or fax, or ask your representative or doctor to ask us for an appeal.

CALL

1-800-399-1954

Monday–Friday, 8 a.m.– 5 p.m.

Calls to this number are free.

“Fast” appeals can be made and are processed 24 hours a day, seven days a week by leaving a voice message at this number.

TTY

711

“Fast” appeals can be made and are processed 24 hours a day, seven days a week by leaving a voice message at this number.

FAX 1-716-731-2013
WRITE

Kalos Health

Appeals and Grievances Department

2424 Niagara Falls Blvd.

Niagara Falls, NY 14304

What happens next?

If you asked for a Level 1 Appeal, you will receive a written notice from Kalos Health that provides you with information concerning our decision about your appeal. If we continue to deny your request for a service, you have other options.

In some cases, we will also automatically send your case to an independent Medicare reviewer. If the independent Medicare reviewer denies your request, the written decision will explain your additional appeal rights.

Contact information

To get more information, or to ask questions about our process or to check the status of an issue, call us at:

1-800-399-1954 (TTY 711)

Monday–Friday, 8 a.m.– 5 p.m.

Other resources to help you:

  • Medicare: 1-800-MEDICARE (1-800-633-4227 or TTY: 1-877-486-2048)
  • Medicare Rights Center: 1-888-HMO-9050

How to file a grievance or make a complaint

A grievance is a type of complaint. You can make a complaint about us or one of our network providers, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about the plan’s coverage or payment, you should look at the section above about making an appeal.)

To make a complaint, call, write, or fax, or ask your representative to make a complaint.

CALL

1-800-399-1954

Monday–Friday, 8 a.m.– 5 p.m.

Calls to this number are free.“Fast” complaints can be made and are processed 24 hours a day, seven days a week by leaving a voice message at this number.

TTY

711

“Fast” complaints can be made and are processed 24 hours a day, seven days a week by leaving a voice message at this number.

FAX 1-716-731-2013
WRITE

Kalos Health

Appeals and Grievances Department

2424 Niagara Falls Blvd.

Niagara Falls, NY 14304

For more information about complaints, see your 2018 Evidence of Coverage (H3227_001_EOC_092017_Accepted.pdf). (You can find the information in Chapter 9.)

You can also get help and information from Medicare

For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare:

  • You can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
  • You can visit the Medicare.gov site to get help with Your Medicare Right (Please note that by clicking on this link, you will leave Kalos Health’s website).
  • Submit a complaint to Medicare, click this link to be redirected to the Medicare the Medicare Complaint Form. (Please note that by clicking on this link, you will leave Kalos Health’s website).

    Appointing a Representative 

    You may appoint someone to act on your behalf and serve as your representative on an appeal. You and your representative must sign the Appointment of Representative Form CMS 1696 (Please note that by clicking on this link, you will leave Kalos Health’s website) and must be included with your appeal. The appointment is valid for one year unless revoked. A copy of this form must be included with any future appeals. If you become incapacitated or of a legally incompetent status, a surrogate may be authorized by the court to act in accordance with State law to file an appeal on your behalf. In this case, an Appointment of Representative Form does not need to be executed. Instead, your surrogate must produce other appropriate legal papers supporting his or her status as your authorized representative when submitted an appeal on your behalf.

    How to Obtain an Aggregate Number of Grievances, Appeals and Exceptions Filed with Kalos Health Gold Plus.

    To obtain an aggregate number of Kalos Health Plans’ grievances, appeals and exceptions, please call Member Services at 1-800-399-1954 from 8:00am – 5:00pm, Monday through Friday.

    For help with complaints, grievances, and information requests, you can contact The Office of the Medicare Ombudsman (OMO).http://www.medicare.gov/Pubs/pdf/11173.pdf (Please note that by clicking on this link, you will leave Kalos Health’s website).

    To file a complaint directly with CMS:https://www.medicare.gov/MedicareComplaintForm/home.aspx (Please note that by clicking on this link, you will leave Kalos Health’s website).

Kalos Health Gold Plus is a Health Maintenance Organization (HMO) Special Needs Plan (SNP) with a Medicare contract and a coordination of benefits agreement with the New York State Department of Health. Enrollment in Kalos Health Gold Plus depends on contract renewal.  This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits  may change on January 1 of each year. You must continue to pay your Medicare Part B premium (unless your part B premium is paid for you by Medicaid or another third party).
H3227_Website_0917_Approved
Last Updated 12-12-2017

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