Grievances and Appeals

Welcome to Doctors HealthCare Plans, Inc.

Thank you for being our member. Your satisfaction is important to us. We are open extended hours year-round to better assist you. Please allow us the opportunity to help and serve you. Please contact us with any questions or concerns.

Doctors HealthCare Plans, Inc.
Member Services Department
2020 Ponce De Leon Blvd., PH 1
Coral Gables, FL 33134
Local: 786-460-3427
Toll-Free: 1-833-342-7463 TTY 711.

We are open 7 days a week, 8:00 a.m. to 8:00 p.m.

Fax: 786-578-0293

Please carefully review the detailed Grievance and Appeal information below along with other important information.

Grievances

The Centers for Medicare and Medicaid Services (CMS) defines a grievance as any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to Doctors HealthCare Plans. Examples of grievances include but are not limited to:

quality of your care during a doctor’s appointment or hospital stay;
waiting times on the phone or at your doctor’s office;
the way your doctor or others behave;
not being able to reach someone by phone or obtain the information you need;
lack of cleanliness or the condition of the doctor’s office.

We will notify you or your authorized representative of the decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. In some cases, we may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

Expedited Grievances

An expedited grievance may also include a complaint that Doctors HealthCare Plans refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame. You have the right to request a fast review or expedited grievance if you disagree with the plan’s decision to provide an extension on your request for an organization determination or reconsideration, or the plan’s decision to process your expedited request as a standard request. We will notify you of our decision about an expedited grievance within 24 hours.

You may call us or submit your written grievance by mail or fax no later than 60 days after the incident to:

Doctors HealthCare Plans, Inc.
Attention: Grievance & Appeals
2020 Ponce De Leon Blvd., PH 1
Coral Gables, FL 33134
Local: 786-460-3427
Toll-Free: 1-833-342-7463 TTY 711.

We are open 7 days a week, 8:00 a.m. to 8:00 p.m.

Fax: 786-578-0293

Please make sure you include your name, member identification number, date of birth, your signature or that of your authorized representative, date, and summary of the incident and supporting information. You may also wish to use the Grievance Form provided below to submit your grievance:

Member Grievance Request Form – English / Spanish

Member Grievance Online Form English / Spanish

Part D Grievances

If you have a problem with your prescription drug coverage, you may file a grievance. A grievance is any complaint, other than one that involves a coverage determination. Some examples of Part D grievances are:

waiting times at the pharmacy to fill your prescription;
long wait times on the phone with the pharmacy;
the way your pharmacist or others within the pharmacy behave;
general complaint about a drug being excluded.

You or your authorized representative may file a grievance orally or in writing to the Appeals & Grievance Department noted above. Please make sure you include your name, member identification number, date of birth, your signature or that of your authorized representative, date, and summary of the incident and supporting information. You may wish to use the Grievance Form provided below to submit your grievance:

Member Grievance Request Form – English / Spanish

Member Grievance Online Form English / Spanish

A Part D grievance must be filed within 60 calendar days after the event or incident that led to your grievance. The plan will notify you or your authorized representative of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. In some cases, we may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. We will notify you of our decision about an expedited grievance within 24 hours.

Please contact us with any help you may need. We will be happy to assist. You may also file a complaint with Medicare by calling 1-800 MEDICARE or visiting https://www.medicare.gov/MedicareComplaintForm/home.aspx, for a Medicare Complaint Form.

Organization Determination (PART C)

Standard

When you, your appointed representative or physician makes a request for a service, Doctors HealthCare Plans must decide as expeditiously as your health condition requires, but no later than 14 calendar days after the date we receive the request for a standard organization determination.

Standard organization determinations decisions will be communicated within 14 calendar days. However, the plan can take an additional 14 calendar days if you ask for additional time, or if we need information that may benefit you.

Expedited

An expedited request can be made if you or your physician believes that waiting for a decision under the standard time frame could place your life, health, or ability to regain maximum function in serious jeopardy. Notification of determination will be provided within 72 hours for expedited organization determination requests. However, under certain circumstances, we can take up to an additional 14 calendar days. If we need additional time to make the decision, we will notify you in writing.

You, your authorized representative or any provider who furnishes or intends to furnish services to you, may request an organization determination by filing a request verbally or in writing to:

Doctors HealthCare Plans, Inc.
2020 Ponce De Leon Blvd., PH 1
Coral Gables, FL 33134
Local: 786-460-3427
Toll-Free: 1-833-342-7463 TTY 711.

We are open 7 days a week, 8:00 a.m. to 8:00 p.m.

Fax: 786-578-0293

Providers, please call:

Medical Management

305-422-9300, option 1

Prior Authorization (Organization Determination) Form English / Spanish

Submit your request online (Request for Prior Authorization online)

Request for Payment (Part C):

Please mail or fax us your written request for payment reimbursement, along with proof of payment (bills, receipts) and/or a copy of the medical record documentation. Please make sure you provide detailed information.

You may wish to use the below Member Reimbursement Request Form:

Member Reimbursement Request Form – English / Spanish

Coverage Determination (Part D)

A Coverage Determination means any decision made by Doctors HealthCare Plans regarding payment or benefit to which you believe you are entitled to. A coverage determination is necessary when a formulary medication requires a Prior Authorization (PA), Step Therapy (ST) and/or Quantity Limit (QL).

Prior Authorization (PA) -Some prescription drugs require prior authorization (PA) to be covered. If your prescription drug requires prior authorization, you, your appointed representative, or your prescribing physician or other prescriber will need to request and receive approval in advance from Doctors HealthCare Plans before you fill your prescription. If you don’t get approval, Doctors HealthCare Plans may not cover the drug.
Step Therapy (ST) – With Step Therapy drugs, Doctors HealthCare Plans may request that you first try certain drugs to treat your medical condition before we cover another drug for that condition. If your drug has a step therapy requirement, your prescribing physician or other prescriber will need to provide a supporting statement to Doctors HealthCare Plans. Approval must be received before you fill your prescription. If you don’t get approval, Doctors HealthCare Plans may not cover the drug.
Quantity Limits (QL) – For certain drugs, Doctors Health Care Plans limits the amount of the drug that will be covered per prescription or for a defined period of time. If you require additional quantities over the limit, your physician will need to provide a supporting statement to Doctors HealthCare Plans. An approval must be received before you fill your prescription for the additional quantity, otherwise the additional quantity may not be covered.
PA, ST and QLs help ensure the best use of your benefits and that you receive the most appropriate treatment. It also avoids the potential misuse and abuse of medication.

Exceptions, such as tiering exceptions and formulary exceptions, also require a coverage determination. A tiering exception is when you believe you should get your drug at a lower cost share. A formulary exception is when you believe you need a drug that is not on the plan’s formulary. All exception requests must be supported by a statement by the prescribing physician.

Doctors Health Care Plans will make standard coverage determinations within 72 hours and expedited coverage determinations within 24 hours.

There are several ways in which you, your appointed representative, your prescribing physician, or other prescriber can request a coverage determination.

Call Member Services toll-free at (833) 342-7463 (TTY: 711), 7 days a week, 8AM to 8PM EST
Submit your Coverage Determination request online (Coverage Determination request online). Supporting documentation will need to be submitted by the prescribing physician or other prescriber to demonstrate medical need.
Download and complete a Coverage Determination form (English / Spanish) and fax the completed form to 858-357-2614
Mail the completed request form to the plan’s Pharmacy Department address:

Doctors HealthCare Plans, Inc.
ATTN: Pharmacy Department
2020 Ponce De Leon Blvd., PH 1
Coral Gables, FL 33134

Request for Payment (Part D):

Please mail or fax us your written request for prescription drug payment reimbursement, along with proof of payment (bills, receipts) and/or a copy of the medical record documentation. Please make sure you provide detailed information. You can download a copy of the below Prescription Drug Claim Form Reimbursement Request Form or send us a letter with all the needed documentation. Please make sure to sign your request. We will notify you of our decision (and make payment when appropriate) no later than 14 calendar days after receiving your request.

Prescription Drug Claim Form – English / Spanish

Appeals

An appeal is a request to Doctors HealthCare Plans to review an unfavorable organization determination (Part C) or coverage determination (Part D). You would file an appeal if you want us to reconsider and change a decision we have made about what Part C and D benefits. You may also file an appeal if you want us to reconsider and change a decision we have made about whether items or services are covered or how much you have to pay for covered items or services.

Part C Appeal (Reconsideration)

You can file your appeal in writing or by fax. You may also use the attached appeal form to submit your appeal:

Part C Member Appeal Request Form – English / Spanish

Once we receive the request, we will notify you of our decision as quickly as your health requires, but no later than 72 hours for expedited requests or 30 calendar days for standard service requests (the plan can take up to an additional 14 calendar days if you request additional time, or if we need additional information that may benefit you), or 60 calendar days for payment requests.

If the decision is unfavorable to you, in whole or in part, the plan must submit the case file and its decision for review to the Part C Independent Review Entity (IRE).

There are five levels in the Medicare Part C appeals process:

First Level: Reconsideration by the Health Plan
Second Level: Reconsideration by an Independent Review Entity (IRE).
Third Level: Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals.
Fourth Level: Review by the Medicare Appeals Council (MAC).
Fifth Level: Judicial Review in Federal District Court.

Part D Appeal (Redetermination)

If Doctors HealthCare Plans issues an adverse coverage determination, you, your prescriber, or representative may appeal the decision to the plan by requesting a standard or expedited redetermination.

Redetermination requests must be filed with the plan within 60 calendar days from the date of the notice of the coverage determination. Standard requests must be made in writing and expedited requests may be made verbally or in writing. You can also submit your Redetermination Request online.

Part D Redetermination Request Form – English / Spanish

On-line submission: (Part D Redetermination Request Online Form)

Once the request is received by the plan, a decision is made and notice is provided as quickly as your health requires, but no later the 72 hours for expedited requests or 7 calendar days for standard requests.

If the decision is unfavorable, the decision letter to you will contain the information you need to file a request for a reconsideration to the Independent Review Entity (IRE).

If you or your representative requires assistance with reconsiderations please call or write us.

There are five levels to the Part D appeals process:

First Level: Redetermination by the Medicare Advantage Part D (MA-PD) Sponsor
Second Level: Redetermination by an Independent Review Entity (IRE)
Third Level: Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals
Fourth Level: Review by the Medicare Appeals Council (MAC)
Fifth Level: Judicial Review in Federal District Court

Aggregate number of grievances, appeals, exceptions filed with the plan

You have the right to get information from Doctors HealthCare Plans regarding the number of appeals, grievances, and exceptions that members have filed with our plan. To get this information, please call our Member Services Department

Doctors HealthCare Plans, Inc.
Attention: Appeals & Grievance Department
2020 Ponce De Leon Blvd., PH 1
Coral Gables, FL 33134
Local: 786-460-3427
Toll-Free: 1-833-342-7463 TTY 711.

We are open 7 days a week, 8:00 a.m. to 8:00 p.m.

Fax: 786-578-0293

How to Appoint a Representative

As a Medicare enrollee, you have the right to ask someone to act on your behalf. You can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.

There may be someone who is already legally authorized to act as your representative under State law.
If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services and request for the “Appointment of Representative” form. The form is also available on Medicare’s website (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf) or by clicking on the attachments below. The form allows you to give a person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give the plan a copy of the signed form.
You may also contact your local Social Security Office.

The appointment is considered valid for one (1) year from the date that the “Appointment of Representative Form” is signed by you (the member) and your legal representative. Also, the representation is valid for the duration of a grievance, a request for organization determination, or an appeal in which it was received with.

For instructions and access to the CMS Appointment of Representation Form (Form CMS-1696), see below:

Instructions on how to Appoint a Representative English / Spanish
Appointment of Representative Form English / Spanish

Once you or your authorized representative have completed and signed the “Appointment of Representative” form you may mail or send via fax.

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Last Updated: 04/17/2023