If you have a problem or complaint (grievances, coverage decisions, appeals), please call us first. Your health and satisfaction are important to us. When you have a problem or concern, we hope you’ll try an informal approach first: please call Customer Service at (503) 345-5702 or (866) 798-2273. We will work with you to try to find a satisfactory solution to your problem.
Refer to the How to sections below.
Grievances or Complaints
Grievances or complaints about quality of care, waiting times and the customer service you receive are examples of the kinds of problems handled through this process. Calling Customer Service is the first step or you may put your complaint in writing and send it to us.
You will find information about Grievances in Chapter 9 of the PremierCare Choice Rx, Value Rx and Plus Evidence of Coverage or in Chapter 7 of the PremierCare Choice Evidence of Coverage. The information is also available by clicking the icon below.
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Appoint a Representative
If a beneficiary would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on his or her behalf, the beneficiary and the person accepting the appointment must fill out form CMS-1696 (or a written equivalent) and submit it with the request.
Click on the icon to view the form CMS-1696 :
Coverage Decisions
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. This is the process you use for issues such as whether something is covered or not and the way in which something is covered. Please call Customer Service at (503) 345-5702 or (866) 798-2273 or contact us in writing.
You will find information about Coverage Decisions and Exceptions in Chapter 9 of the PremierCare Choice Rx, Value Rx and Plus Evidence of Coverage or in Chapter 7 of the PremierCare Choice Evidence of Coverage. The information is also available by clicking the icon below.
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How to Appeal a Coverage Decision
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
You can contact us in writing or by phone to make a complaint or an appeal. To contact us by telephone, call Customer Service, Monday through Friday from 8 am to 8 pm toll-free at (503) 345-5702 or (866) 798-2273, TTY (800) 735-2900.
You will find information about Appeals in Chapter 9 of the PremierCare Choice Rx, Value Rx and Plus Evidence of Coverage or in Chapter 7 of the PremierCare Choice Evidence of Coverage. The information is also available by clicking the icon below.
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Request for a Medicare Prescription Drug Coverage Determination
A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this Medicare coverage determination model form to request an initial coverage determination (decision) on a Medicare Part D medication that requires prior authorization from FamilyCare.
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Request for Redetermination of Medicare Drug Denial
If a Medicare Part D medication was initially denied, a beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this Medicare redetermination model form to request a redetermination (appeal) with FamilyCare.
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Quality Improvement Organization
There is a Quality Improvement Organization in each state. In Oregon the Quality Improvement Organization is called Acumentra Health. Acumentra Health has a group of doctors and other health care professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare.
You should contact Acumentra Health if you have a complaint about the quality of care you have received, or you think coverage for your hospital stay, home healthcare, skilled nursing facility care or Comprehensive Outpatient Rehabilitation Facility (CORF) is ending too soon.
You can contact Acumentra Health at (503) 279-0100 or in writing at 2020 SW Fourth Avenue, Suite 520, Portland, OR 97201.