An organization determination (coverage decision) is the initial decision we make about your benefits and coverage. It can also be about the amount we will pay for your medical services or drugs. If you are having problems getting medical care, a service you requested, or payment (including the amount you have already paid) for medical care or services you have already received, then you can resolve the problem through an organization determination. If your health requires a quick response, you should ask us to make a "fast decision." If we say no, you have the right to ask us to reconsider—and perhaps change—this decision by making an appeal.

If we make a coverage decision and you are not satisfied with part or all of our decision, you or your representative can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. If your health requires a quick response, you must ask for a "fast appeal." When you make an appeal, we review the coverage decision we have made to check to see if we were following all the benefits properly. When we have completed the review, we will give you our decision in writing. If we say no to all or part of your Level 1 Appeal, your appeal will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our Plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal. These additional levels are explained in your Evidence of Coverage.

A grievance is any complaint, other than one that involves a request for an initial determination or an appeal as described in the determinations and appeals section of your Evidence of Coverage. If you have a complaint about quality of care, waiting times, or the customer service you receive, you or your representative may call 888-850-8526 (TTY/TDD: 711). We will try to resolve your complaint over the phone. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the Premera Blue Cross Medicare Advantage Plans Grievance Procedure. To use the formal grievance procedure, you may submit your written grievance to the Premera Blue Cross Medicare Advantage Appeals and Grievance Department. If you file a written grievance, or your complaint is related to quality of care and we have your consent to investigate, we will respond in writing to you.

To file a grievance, you or your representative may:

• Call: 888-850-8526 (TTY/TDD: 711)
  
• Fax: 800-889-1076
• Write:
  Premera Blue Cross Medicare Advantage Plans
  Attn: Appeals and Grievances Department
  PO Box 21481
  Eagan, MN 55121

For quality-of-care problems, you may also complain to the Quality Improvement Organization (QIO).

You may complain about the quality of care you received, including care during a hospital stay. 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. Please refer to Chapter 2, Section 4, of your Evidence of Coverage for additional information about the Quality Improvement Organization in your state.

The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests.

If you would like someone else to act on your behalf, please fill out this form (.pdf), sign it, and return it to us.

Mail to:

Premera Medicare Advantage Plans
PO Box 21481
Eagan, MN 55121
Fax: 800-390-9656