Grievances and Appeals

Important Information About Your Appeal Rights for Services, Supplies and Non-Part D Drugs

There are 2 kinds of appeals

Standard Appeal – We’ll give you a written decision on a standard appeal within 30 calendar 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’ll tell you if we’re taking extra time and will explain why more time is needed. If your appeal is for payment of a service you’ve already received, we’ll give you a written decision within 60 calendar days.

Fast Appeal – We’ll give you a decision on a fast appeal within 72 hours after we get your appeal. You can ask for a fast appeal if you or your provider believe your health could be seriously harmed by waiting up to 30 calendar days for a decision.

We’ll automatically give you a fast appeal if a provider asks for one for you or supports your request. If you ask for a fast appeal without support from a provider, we’ll decide if your request requires a fast appeal. If we don’t give you a fast appeal, we’ll give you a decision within 30 calendar days.

How to ask for an appeal with Neighborhood

Step 1: You, your representative, or your provider must ask us for an appeal. Your request must include:

• Your name
• Address
• Member number
• Reasons for appealing
• Any evidence you want us to review, such as medical records, doctors’ letters, or other information that explains why you need the item or service. Call your provider if you need this information.

You can ask to see the medical records and other documents we used to make our decision 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.

Step 2: Mail, fax, or deliver your appeal or call us.

For a Standard Appeal:    

Address:
Grievance and Appeals Coordinator
Neighborhood Health Plan of Rhode Island
910 Douglas Pike
Smithfield, RI 02917

Phone: 1-844-812-6896
Fax: 1-401-709-7005

If you ask for a standard appeal by phone, we will send you a letter confirming what you told us.

For a Fast Appeal:  
Phone: 1-844-812-6896
Fax: 1-401-709-7005

What happens next?

If you ask for an appeal and we continue to deny your request for payment of a service, we’ll send you a written decision. The letter will tell you if the service or item is usually covered by Medicare and/or Medicaid.

• If the service is covered by Medicare, we will automatically send your case to an independent reviewer. If the independent reviewer denies your request, the written decision will explain if you have additional appeal rights.
• If the service is covered by Medicaid, you can ask for a State Fair Hearing. You may also ask for an External Review if the service you are requesting requires a medical necessity review. Both the State Fair Hearing and the External Review are conducted by independent entities that are not part of the plan. Your written decision will give you instructions on how to request an external review and/or State Fair Hearing.
• If the service could be covered by both Medicare and Medicaid, we will automatically send your case to the independent reviewer. You can also ask for a hearing with the RI External Review organization and/or State Fair Hearing office. Your written decision will give you instructions on how to request either or both of these appeal processes.

For more information about the appeals process, please refer to your Member Handbook or call Member Services at 1-844-812-6896 (TTY 711), 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday. On Saturday afternoons, Sundays and holidays, you may be asked to leave a message. Your call will be returned within the next business day.

Get help & more information:

Neighborhood Health Plan of Rhode Island:  If you need help or additional information about our decision and the appeal process, call Member Services at: 1-844-812-6896 (TTY: 711), 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday. On Saturday afternoons, Sundays and holidays, you may be asked to leave a message. Your call will be returned within the next business day.

• Medicare:  1-800-MEDICARE (1-800-633-4227 or TTY: 877-486-2048), 24 hours a day, 7 days a week
• Medicare Rights Center:  1-888-HMO-9050
• Elder Care Locator:  1-800-677-1116
• The POINT: 1-401-462-4444 (TTY: 711)

Standard Part D Appeal

If you don’t agree with a decision we make about a prescription drug covered by Medicare, you have the right to appeal.

We’ll give you a written decision on a standard appeal seven calendar 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’ll tell you if we’re taking extra time and will explain why more time is needed.

If your appeal is for payment of a drug you’ve already received and received a denial for, we’ll give you a written decision within 60 calendar days.

Fast (Expedited) Part D (Prescription Drug) Appeal

Sometimes waiting 30 calendar days for a coverage decision could seriously jeopardize your ability to attain, maintain, or regain maximum function. If you or your providers believe your request must be reviewed quickly, you can ask for a fast review, known as an expedited appeal, by contacting Member Services at 1-844-812-6896; TTY users should call 711. We are open 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday.

If your request is approved for an expedited appeal, a coverage decision will be made and you and your provider will be notified no later than seventy-two (72) hours after receipt of your appeal.  We will call you and your provider to let you know our decision.

To request a Part D (Prescription Drug) Appeal, call, mail, or fax your request to:

CVS Caremark Part D Appeals and Exceptions
PO BOX 52000 MC109
Phoenix, AZ 85072-2000
Appeals fax: 1-855-633-7673

To request reimbursement for a Part D Prescription you paid out of pocket for, please mail a copy of your receipt and related prescription documentation to:

CVS Caremark Part D Appeals and Exceptions
PO BOX 52066
Phoenix, AZ  85072-2066
Paper Claims Appeals fax: 1-855-230-5549

Appointing a Representative

If you need someone to file a grievance (a complaint) or appeal on your behalf, you can name a relative, friend, advocate, provider, or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

If you are requesting a prior approval through an appointed representative, click on the link below to download a copy of the Authorized Representative Form. Please complete it, and fax or mail it to:

A Grievance is a complaint about anything other than benefits, coverage, or payment. You would file a grievance if you had any type of problem with the quality of your medical care, waiting times, or the customer service you receive. You would also file a grievance if you did not think we had responded quickly enough to your request for coverage determination or organization determination, or to your appeal. Grievances are responded to with 30 calendar days.

Filing a Grievance

You or your appointed representative can file a grievance verbally by calling Member Services at 1-844-812-6896 (TTY 711), 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday. On Saturday afternoons, Sundays and holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free.

You can also submit a grievance in writing or in person.  Your request should include:

• Your name
• Address
• Neighborhood member identification number
• Reasons why you are not happy

To request a grievance, mail, or fax your request to:

Helpful Links 2019

• Appointment of Representative (AOR) Form
• Part D Redetermination Request Form – Coming Soon
• Enrollee Appeal Request Form
• Enrollee Grievance Request Form
• File a complaint directly with CMS

Contact Information

How to Obtain an Aggregate Number of Grievances, Appeals and Exceptions Filed with Neighborhood: To obtain an aggregate number of grievances, appeals and exceptions, please call Member Services at 1-844-812-6896 (TTY 711), 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday.

On Saturday afternoons, Sundays and holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free.

Legal Services (Rhode Island) 
1-401-274-2652

Rhode Island Insurance Resource, Education, and Assistance Consumer Helpline 
1210 Pontiac Avenue
Cranston, RI 02920
Telephone: 1-855-747-3224 (855-RIREACH)
Web site: www.rireach.org 
E-mail: rireach@ripin.org