What is a grievance?   A grievance is a type of complaint you can make for situations that don't involve coverage or payment for your prescription(s), such as the pharmacy placed you on hold too long or the pharmacy staff was not friendly.  You can also file a grievance if your plan disenrolls you without your request.  A grievance may also include that your plan refused to expedite a coverage determination or redetermination.  Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item.

Informal Grievance :  This is a complaint made by phone.  We encourage you to call us when you have a complaint.  This way, we can attempt to resolve your concern quickly and we feel that speaking with you directly can help us to better understand your concern.  To submit an informal grievance by phone, call 1-877-545-7384; TTY: 1-800-349-3538. To submit an informal grievance in person, visit us at Spectrum Care Plus/Member Services, 2720 North Tenaya Way, Las Vegas, NV 89128.  Hours of operation are 8 a.m. - 8 p.m., 5 days a week

Formal Grievance :  This is a complaint made in writing.  It can also be considered a formal grievance if it is received verbally and is a quality of care complaint (determined by Spectrum Care Plus). To submit a formal grievance by fax, fax 702-242-7655; from 8 a.m. - 8 p.m., 5 days a week. To submit a formal grievance in writing, mail to Spectrum Care Plus/Government Programs, Grievance Request, P.O. Box 15645, Las Vegas, NV 89114-5645.  Please include any information or documents that may support your request.  We will send you an acknowledgement letter to let you know we received it.  We will reply to your written grievance/complaint in writing within 30 calendar days.  The 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.  We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.

Fast/Expedited Grievance:  In certain cases, you have the right to ask for a "fast grievance," meaning we will answer your grievance within 24 hours.  You have the right to file a fast grievance if you disagree with our decision to deny your request for a fast review of your initial determination request or redetermination request.  If you ask for a fast decision without support from a doctor, we will decide if your health requires a fast decision.  If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter informing you that if you get a doctor's support for a fast review, we will automatically give you a fast decision.

Initial Determinations - The initial determination we make is the starting point for dealing with requests you may have about covering a Part D drug, or paying for a Part D drug you already received.  Initial decisions about Part D drugs are called "coverage determinations."  With this decision, we explain whether we will provide the Part D drug you are requesting, or pay for the Part D drug you already received.  For a standard initial determination, we must give you our decision no later than 72 hours after we receive your request, but we will make it sooner if your request is for a Part D drug that you have not received yet or your health condition requires us to.  For a fast initial determination about a Part D drug that you have not yet received, we will give you our decision within 24 hours after you or your doctor ask for a fast review.  We will give you the decision sooner if your health condition requires us to.  If your request involves a request for an exception, we will give you our decision no later than 24 hours after we have received your physician's "supporting statement," which explains why the drug you are asking for is medically necessary.  If we decide you are eligible for a fast review and you have not received an answer from us within 24 hours after receiving your request (or your physician's supporting statement if your request involves an exception), your request will automatically go to Appeal Level 2.  If an initial determination does not give you all that you requested, you have the right to appeal the decision.

What is an appeal?  An appeal is a request to reconsider a decision that was not in your favor (in whole or in part).  You may ask us to review our initial determination, even if only part of our decision is not what you requested.  An appeal to the Plan about a Part D drug is also called a Plan "redetermination."  When we receive your request to review the initial determination, we give the request to people at our organization who were not involved in making the initial determination.  This helps ensure that we will give your request a fresh look.  The Appeals process relates to the reconsideration of decisions regarding coverage or payment of a drug, such as you were denied coverage or payment for a drug that you believe should be covered or paid.  Appeals include redeterminations by the plan, reconsiderations by the independent review entity (IRE), Administrative Law Judge (ALJ) hearings, reviews by Medicare Appeals Council (MAC) and judicial reviews.

How soon must we decide on your appeal?

For a standard appeal about a Part D drug that includes a request to pay you back for a Part D drug you have already paid for and received, we will give you our decision within seven calendar days of receiving the appeal request.  We will give you the decision sooner if you have not received the drug yet and your health condition requires us to.  If we do not give you our decision within seven calendar days, your request will automatically go to Appeal Level 2.

To submit a standard appeal in writing, mail to Spectrum Care Plus/Government Programs, P.O. Box 15645, Las Vegas, NV 89114-5645.

Expedited or fast appeal:  This is an appeal that is handled more quickly than the regular or standard appeal.  It is handled more quickly because it is determined to be time sensitive.  That is, it involves a situation where waiting for a standard decision could seriously jeopardize your life or health, or your ability to regain maximum function.  You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or ability to function. (Fast decisions apply only to requests for Part D drugs that you have not received yet.  You cannot get a fast decision if you are requesting payment for a Part D drug that you already received.) 

For a fast appeal about a Part D drug that you have not yet received, we will give you our decision within 72 hours after we receive the appeal request.  We will give you the decisions sooner if your health condition requires us to.  If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

To submit a fast appeal by phone, call 1-877-545-7384; TTY: 1-800-349-3538.  To submit by fax, fax to 702-242-7655.  To submit a fast appeal in person, visit us at Spectrum Care Plus/Member Services, 2720 North Tenaya Way, Las Vegas, NV 89128.  Hours of operation are 8 a.m. - 8 p.m., 5 days a week.

Additional important information about Appeals and Grievance Rights can be found by clicking on the button to your left.

You can also review your Evidence of Coverage for appeals and grievance information.  To access your Evidence of Coverage from this Web site, click here .  Appeals and grievance information is listed under Chapter 9 of the Evidence of Coverage.  For information on how to obtain an aggregate number of appeals, grievances, and exceptions filed with the plan, please contact Member Services.

If you have any questions or would like to inquire about the status of an appeal, you or your provider may call Spectrum Care Plus at 1-877-545-7384; TTY: 1-800-349-3538.  Hours of operation are 8 a.m. - 8 p.m., 5 days a week.