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Problems, Concerns, & Complaints

2017 Problems, Concerns, & Complaints

FamilyCare Health is here to help.

FamilyCare Health is committed to giving you the best care possible. If you have questions or suggestions for us, want to alert us of a concern or problem, or want to file a complaint, we are here to listen.

Know your rights and responsibilities

As a member of FamilyCare Health, you have rights. We have established a code of conduct designed to:

  • Protect you when you get health care
  • Make sure you get the healthcare services that the law says you can get
  • Protect you against unethical practices
  • Protect your privacy

You can view or print the complete list of FamilyCare Health member rights and responsibilities. If you choose to disenroll, you can find instructions here. 

Contact us with any concern:

You, your doctor, or your designated representative* can contact FamilyCare Health about any problems or concerns you have. To contact us:

  • Call: 503-345-5702 or toll-free 866-798-2273 (TTY/TTD 711). You can call us from 8 a.m. to 8 p.m., seven days a week, from October 1 through February 14 (except Thanksgiving and Christmas**). From February 15 to September 30, you can reach us Monday through Friday from 8 a.m. to 8 p.m. and on weekends from 9 a.m. to 5 p.m. (except Memorial Day, Independence Day, and Labor Day**).
  • Write to: FamilyCare Health
    825 NE Multnomah St., Suite 1400
    Portland, OR 97232
  • Fax: 503-345-5720

* In order to appoint a representative to submit a complaint or problem on your behalf, you and your representative must read the instructions and fill out form CMS-1696 (or a written equivalent) and submit it with the request. 

You can also use this information to get information about the status of your complaint.

To learn more about what happens after you file a complaint, see your plan’s Evidence of Coverage. (Go to our 2017 Medicare Advantage Plans page and click the link to your plan.)  

Complaints about a provider, pharmacy or facility

If you have a problem with how you’ve been treated or with access to healthcare services or providers, let us know promptly by filing a grievance. This grievance must be submitted within 60 days of the event or incident. 

We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint.

If your complaint has not been handled by FamilyCare Health to your satisfaction, you may send a complaint directly through Medicare. You can do so with the Medicare Complaint Form on the Medicare website or call 1-800-MEDICARE (800-633-4227). TTY/TTD users can call 1-877-486-2048.

Complaints about quality of care

When your complaint is about quality of care, you can complain to us or to Oregon’s Quality Improvement Organization (QIO), Livanta. The QIO is a group of practicing doctors and other healthcare experts paid by the Federal government to check and improve care that Medicare patients receive. If you make a complaint to this organization, we will work with them to resolve your complaint, whether or not you also file a complaint with us.

You can reach Livanta at:

Livanta
10830 Guilford Rd., Suite 312
Annapolis Junction, MD 20701
Call: 877-588-1123 toll-free
TTY: 855-887-6668 toll-free

How to request a medical coverage decision

If you are concerned about the amount you pay for a medical service, you can ask us to make an exception. This is also called a “coverage decision.” 

Some reasons you might ask us for a coverage decision include:

  • You requested or received care that you believe should be covered by the plan, but we have said we will not pay for this care.
  • You received and paid for care that you believe should be covered by the plan, and you want us to reimburse you.
  • You are told that coverage for certain medical care you have been getting and that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.
  • You believe you paid more than you should have for covered care.

In most cases, we will give you an answer within 14 days of receiving your request. If your health requires it, ask us to give you a “fast coverage decision.” A fast coverage decision means we will answer you within 72 hours.

You can request a coverage decision by phone, email, or in writing. If you put your complaint in writing, we will respond to you in writing. The complaint (also called a grievance) must be submitted within 60 days of the event or incident. We will work with you to try to find an acceptable solution to your problem.

You, your doctor, or your designated representative can contact us at: 503-345-5702 or toll-free 866-798-2273  (TTY/TTD 711). You can reach us from 8 a.m. to 8 p.m., seven days a week, from October 1 through February 14 (except Thanksgiving and Christmas**). From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. and on weekends from 9 a.m. to 5 p.m. (except Memorial Day, Independence Day, or Labor Day**).

You can also write or fax us at:

FamilyCare Health 
825 NE Multnomah St., Suite 1400
Portland, OR 97232
Fax: 503-345-5720

We must address your grievance as quickly as your case requires based on your health status, but, in general, no later than 30 days after receiving your complaint.

If you would like to send a complaint directly through Medicare, you can do so on the Medicare Complaint Form on the Medicare website. You can also call 800-MEDICARE (800-633-4227). Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.

How to request an exception for a drug

We want to hear if you have problems getting a Medicare Part D drug, if you want us to pay you back for a Part D drug, or if a drug is not covered in the way you would like it to be covered. 

If you are asking us to make a change just for you to our formulary or our drug tiers, your doctor or other prescriber must give us a statement that explains the medical reasons for “requesting an exception.” Examples of a request for an exception include:

  • Asking us to cover a Part D drug that is not on our list of covered drugs
  • Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get)
  • Asking to pay a lower cost-sharing amount for a covered non-preferred drug

To request an exception specifically for prescription drug coverage, you, your representative, or your doctor may fill out our prescription drug coverage request form. Or you may use this Medicare Coverage Determination form instead. 

For more information about your rights when we change our formulary (for example if you are taking a drug that was covered differently on the previous formulary), see our Prescription Drug Transition Policy.

How to appeal a decision about medical or drug coverage 

If we tell you that we will not cover or pay for a medical service or drug in the way that you want it to be covered, then you can make an appeal. This means you are asking us to reconsider our coverage decision.

Examples of appeals include: 

  • You disagree with a coverage decision we made
  • You disagree with a decision we made about your request for a prescription drug exception

If we denied a request about a Medicare Part D drug, you, your representative, or your health provider may use this form to ask us to reconsider our decision.

As with other complaints and concerns, you can contact us in writing or by phone to appeal a decision we made. You may contact Navigation Services at 503-345-5702 or toll-free 866-798-2273 (TTY/TDD 711). To reach us via mail, write to FamilyCare Health, 825 NE Multnomah St., Portland, OR 97232. We must consider your appeal and will gather more information if necessary. If we say no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process. 

How many formal complaints has FamilyCare Health received?

To find out how many total grievances, appeals and exceptions have been filed with FamilyCare Health, contact Navigation Services at 503-345-5702 or toll-free 866-798-2273 (TTY/TDD 711). You can reach us from 8 a.m. to 8 p.m., seven days a week, from October 1 through February 14 (except Thanksgiving and Christmas**). From February 15 to September 30, call us Monday through Friday from 8 a.m. to 8 p.m. and on weekends from 9 a.m. to 5 p.m. (except Memorial Day, Independence Day, or Labor Day**).

**On these holidays, you can leave a voice message and we will get back to you within one business day.

FamilyCare Health, Inc., is an HMO plan with a Medicare contract and a contract with the Oregon Health Plan (Medicaid). Enrollment in FamilyCare Health depends on contract renewal.

Y0103_WEB_00317v2 — Approved (Updated 06/12/2017)

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