Appeals & Grievances

Appeals & Grievances - Part C

Each member has the right to file a complaint, grievance or appeal, either directly with the plan or through Medicare. Here we will explain the difference between a complaint or appeal and the process that you must follow when filing with our plan.

 

To file a complaint with Medicare you may call 1-800-Medicare, 24 hours a day, 7 days a week. TTY users (hearing impaired) should call 1-877-486-2048. You may also access the Medicare Complaint Form

 

Plans are expected to disclose grievance, and appeals, upon request, to individuals eligible to elect a Medicare Advantage organization or a Part D Sponsor.  If you are interested in receiving this information, please contact Member Services: 

 

 

MMM

Member Services:

787-620-2397 (Metro Area)

1-866-333-5470 (toll free)

1-866-333-5469 TTY

(hearing impaired)

 

PMC

Member Services:

787-625-2126 (Metro Area)

1-866-516-7700 (toll free)

1-866-516-7701 TTY

(hearing impaired)

 

First+Plus

Member Services:

787-522-7800 (Metro Area)

1-888-767-7717 (toll free)

1-877-672-4242 TTY

(hearing impaired)

 

 

Monday through Sunday, from 8:00 a.m. to 8:00 p.m.

Grievances

  • A grievance is any complaint, other than one that involves a request for an initial determination or an appeal.

     

    Grievances do not involve problems related to approving or paying for Part C medical care or services, problems about having to leave the hospital too soon, and problems about having Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending too soon.

     

    If we will not pay for or give you the Part C medical care or services you want, you believe that you are being released from the hospital or SNF too soon, or your HHA or CORF services are ending too soon, you must follow the rules outlined in the Appeals section.

    • Problems with the service you receive from Customer Services.

    • If you feel that you are being encouraged to leave (disenroll from) the Plan.

    • If you disagree with our decision not to give you a "fast" decision or a "fast" appeal.

    • We don't give you a decision within the required time frame.

    • We don't give you required notices.

    • You believe our notices and other written materials are hard to understand.

    • Problems with the quality of the medical care or services you receive, including quality of care during a hospital stay.

    • Problems with how long you must wait on the phone, in the waiting room, or in the exam room.

    • Problems getting appointments when you need them, or waiting too long for them.

    • Rude behavior by doctors, nurses, receptionists, or another staff.

    • Cleanliness or condition of doctor's offices, clinics, or hospitals.

    • If you have one of these types of problems and want to make a complaint, it is called "filing a grievance."

  • You or someone you name may file a grievance. The person you name would be your “representative.”  You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. You must complete the Appointment of Representative form.

     

    For more information, call Member Services.

  • If you have a complaint, you or your representative may call Member Services We will try to resolve your complaint over the phone. If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this MMM Healthcare, LLC Grievance Process.  Please tell the Customer Representative that you want to file a grievance.  In return, the Customer Representative will forward your grievance request for processing.  You may file your grievance verbally or in writing.  If you want to write to us rather than file a verbal grievance, you may address your correspondence to the following address:

     

    Medicare y Mucho Más

    Appeals and Grievances
    PO BOX 71114 
    San Juan, PR 00936-8014

    Fax: 787-625-3375

    mmm@mmmhc.com

     

    PMC Medicare Choice

    Appeals and Grievances
    PO BOX 71114 
    San Juan, PR 00936-6292

    Fax:  787-625-3375

    pmc@pmc-pr.com

     

    First+Plus

    Appeals and Grievances
    PO BOX 71114
    San Juan, PR 00936-8014

    Fax:  787-625-3375

    mmm@mmmhc.com

     

     

    If your complaint involves a refusal to grant a request for an expedited coverage determination or an expedited redetermination and you have not purchased or received the drug in dispute, we must respond to your grievance within 24 hours.

     

    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.  If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have. 

  • In certain cases, you have the right to ask for a “fast grievance,” meaning we will answer your grievance within 24 hours. 

  • The Quality Improvement Organization (QIO) is a group of doctors and other health care experts paid by the federal government to check on and help improve the care given to Medicare patients. They are not part of the Plan or the hospital. For Puerto Rico this organization is called Livanta, LLC. The doctors and other health experts in Livanta review certain types of complaints made by Medicare patients. These include complaints from Medicare patients who think their hospital stay is ending too soon.

     

    You may complain about the quality of care received under Medicare, including care during a hospital stay. You may complain to us using the grievance process, to the Quality Improvement Organization (QIO), or both. If you file with the QIO, we must help the QIO resolve the complaint.

     

    You or your authorized representative may contact Livanta by phone or in writing:

     

    LIVANTA
    BFCC-QIO Program, Area 1
    9090 Junction Drive, Suite 10
    Annapolis Junction, MD 20701
    Tel: 1-866-815-5440
    TTY: 1-866-868-2289
    Web site: www.bfccqioarea1.com

     

Appeals

  • 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 Part C medical care or services is also called plan "reconsideration." 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.

     

    Who may file your appeal of the initial determination?

     

    If you are appealing an initial decision about Part C medical care or services, the rules about who may file an appeal are the same as the rules about who may ask for an organization determination. Follow the instructions under “Who may ask for an initial determination?”  However, providers who do not have a contract with the Plan may also appeal a payment decision as long as the provider signs a “waiver of payment” statement saying it will not ask you to pay for the Part C medical care or service under review, regardless of the outcome of the appeal.

     

    How soon must you file your appeal?

     

    You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

     

    How to file your appeal?

    • Asking for a standard appeal - To ask for a standard appeal about a Part C medical care or service, you should send a written and signed appeal request by mail or fax.

    • Asking for a fast appeal - If you are appealing a decision we made about giving you a Part C medical care or service that you have not received yet, you and/or your doctor will need to decide if you need a fast appeal. The rules about asking for a fast appeal are the same as the rules about asking for a fast initial determination. You, your doctor, or your representative may ask us for a fast appeal by calling or sending a letter by fax or mail.

    Medicare y Mucho Más

    Appeals and Grievances
    PO BOX 71114 
    San Juan, PR 00936-8014

    Fax: 787-625-3375

    mmm@mmmhc.com

     

    PMC Medicare Choice

    Appeals and Grievances
    PO BOX 366292 
    San Juan, PR 00936-6292

    Fax: 787-625-3375

    pmc@pmc-pr.com

     

    First+Plus

    Appeals and Grievances
    PO BOX 71114
    San Juan, PR 00936-8014

    Fax: 787-625-3375

    mmm@mmmhc.com

     

    Be sure to ask for a "fast" or "expedited" review. Remember, if your doctor provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically give you a fast appeal. 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. The letter will also tell you how to file a “fast grievance.” You have the right to file a fast grievance if you disagree with our decision to deny your request for a fast review (for more information about fast grievances, see your Evidence of Coverage). If we deny your request for a fast appeal, we will give you a standard appeal. 

     

    Please note that even when the initial coverage determination and the appeals process is the same, the appeals are managed by our Appeals and Grievances Department. 

     

    Getting information to support your appeal

     

    We must gather all the information we need to make a decision about your appeal. If we need your assistance in gathering this information, we will contact you, your representative or your physician. You have the right to obtain and include additional information as part of your appeal. For example, you may already have documents related to your request, or you may want to get your doctor’s records or opinion to help support your request. You may need to give the doctor a written request to get information.

     

    You may give us your additional information to support your appeal by calling or sending a letter by fax or mail.

     

    Medicare y Mucho Más

    Appeals and Grievances
    PO BOX 71114 
    San Juan, PR 00936-8014

    Fax: 787-625-3375

    mmm@mmmhc.com

     

    PMC Medicare Choice

    Appeals and Grievances
    PO BOX 366292 
    San Juan, PR 00936-6292

    Fax: 787-625-3375

    pmc@pmc-pr.com

     

     

    First+Plus

    Appeals and Grievances
    PO BOX 71114
    San Juan, PR 00936-8014

    Fax: 787-625-3375

    mmm@mmmhc.com

     

    You also have the right to ask us for a copy of information regarding your appeal.

     

    How soon must we decide on your appeal?

     

    For a decision about payment for Part C medical care or services you already received.

    • After we receive your appeal request, we have 60 days to decide. If we do not decide within 60 days, your appeal automatically goes to Appeal Level 2.

    For a standard decision about Part C medical care or services you have not yet received.

    • After we receive your appeal, we have 30 days to decide, but will decide sooner if your health condition requires. However, if you ask for more time, or if we find that helpful information is missing, we can take up to 14 more days to make our decision. If we do not tell you our decision within 30 days (or by the end of the extended time period), your request will automatically go to Appeal Level 2.

    For a fast decision about Part C medical care or services you have not yet received.

    • After we receive your appeal, we have 72 hours to decide, but will decide sooner if your health condition requires. However, if you ask for more time, or if we find that helpful information is missing, we can take up to 14 more days to make our decision. If we do not decide within 72 hours (or by the end of the extended time period), your request will automatically go to Appeal Level 2.

     

    What happens if we decide completely in your favor?

     

    For a decision about payment for Part C medical care or services you already received.

    We must pay within 60 days of receiving your appeal request.

     

    For a standard decision about Part C medical care or services you have not yet received. We must authorize or provide your requested care within 30 days of receiving your appeal request. If we extended the time needed to decide your appeal, we will authorize or provide your requested care before the extended time period expires.

     

    For a fast decision about Part C medical care or services you have not yet received.

    We must authorize or provide your requested care within 72 hours of receiving your appeal request. If we extended the time needed to decide your appeal, we will authorize or provide your requested care before the extended time period expires.

  • At the second level of appeal, your appeal is reviewed by an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this entity.

     

    How to file your appeal?

    If you asked for Part C medical care or services, or payment for Part C medical care or services, and we did not rule completely in your favor at Appeal Level 1, your appeal is automatically sent to the IRE.

     

    How soon must the IRE decide?

    The IRE has the same amount of time to make its decision as the plan had at Appeal Level 1.

     

    What happens if the IRE decides completely in your favor?

    The IRE will tell you in writing about its decision and the reasons for it.

     

    For a decision about payment for Part C medical care or services you already received: We must pay within 30 days after we receive notice reversing our decision.

     

    For a standard decision about Part C medical care or services you have not yet received: We must authorize your requested Part C medical care or service within 72 hours, or provide it to you within 14 days after we receive notice reversing our decision.

     

    For a fast decision about Part C medical care or services: We must authorize or provide your requested Part C medical care or services within 72 hours after we receive notice reversing our decision.

     

  • If the IRE does not rule completely in your favor, you or your representative may ask for a review by an Administrative Law Judge (ALJ) if the dollar value of the Part C medical care or service you asked for meets the minimum requirement provided in the IRE’s decision. During the ALJ review, you may present evidence, review the record (by either receiving a copy of the file or accessing the file in person when feasible), and be represented by counsel.

     

    How to file your appeal?

    The request must be filed with an ALJ within 60 calendar days of the date you were notified of the decision made by the IRE (Appeal Level 2). The ALJ may give you more time if you have a good reason for missing the deadline. The decision you receive from the IRE will tell you how to file this appeal, including who can file it.

    The ALJ will not review your appeal if the dollar value of the requested Part C medical care or service does not meet the minimum requirement specified in the IRE's decision. If the dollar value is less than the minimum requirement, you may not appeal any further.

     

    How soon will the Judge make a decision?

    The ALJ will hear your case, weigh all of the evidence, and make a decision as soon as possible.   If the Judge decides in your favor: See the section “Favorable Decisions by the ALJ, MAC, or a Federal Court Judge” below for information about what we must do if our decision denying what you asked for is reversed by an ALJ.

  • If the ALJ does not rule completely in your favor, you or your representative may ask for a review by the Medicare Appeals Council (MAC).

     

    How to file your appeal?

    The request must be filed with the MAC within 60 calendar days of the date you were notified of the decision made by the ALJ (Appeal Level 3). The MAC may give you more time if you have a good reason for missing the deadline. The decision you receive from the ALJ will tell you how to file this appeal, including who can file it.   

     

    How soon will the Council make a decision?

    The MAC will first decide whether to review your case (it does not review every case it receives). If the MAC reviews your case, it will make a decision as soon as possible. If it decides not to review your case, you may request a review by a Federal Court Judge (see Appeal Level 5). The MAC will issue a written notice explaining any decision it makes. The notice will tell you how to request a review by a Federal Court Judge.

     

    If the Council decides in your favor:

    See the section “Favorable Decisions by the ALJ, MAC, or a Federal Court Judge” below for information about what we must do if our decision denying what you asked for is reversed by the MAC.

  • You have the right to continue your appeal by asking a Federal Court Judge to review your case if the amount involved meets the minimum requirement specified in the Medicare Appeals Council's decision, you received a decision from the Medicare Appeals Council (Appeal Level 4), and:

    • The decision is not completely favorable to you, or

    • The decision tells you that the MAC decided not to review your appeal request.

     

    How to file your appeal?​

    In order to request judicial review of your case, you must file a civil action in a United States district court within 60 calendar days after the date you were notified of the decision made by the Medicare Appeals Council (Appeal Level 4). The letter you get from the Medicare Appeals Council will tell you how to request this review, including who can file the appeal.

       

    Your appeal request will not be reviewed by a Federal Court if the dollar value of the requested Part C medical care or service does not meet the minimum requirement specified in the MAC’s decision.

     

    How soon will the Judge make a decision?

    The Federal Court Judge will first decide whether to review your case. If it reviews your case, a decision will be made according to the rules established by the Federal judiciary.

     

    If the Judge decides in your favor:

    See the section “Favorable Decisions by the ALJ, MAC, or a Federal Court Judge” below for information about what we must do if our decision denying what you asked for is reversed by a Federal Court Judge.

     

    If the Judge decides against you: You may have further appeal rights in the Federal Courts. Please refer to the Judge’s decision for further information about your appeal rights.

     

    Favorable Decisions by the ALJ, MAC, or a Federal Court Judge  

    This section explains what we must do if our initial decision denying what you asked for is reversed by the ALJ, MAC, or a Federal Court Judge.

    • For a decision about Part C medical care or services, we must pay for, authorize, or provide the medical care or service you have asked for within 60 days of the date we receive the decision.

     

Appeals - Hospital Discharge

 

If you think you are being discharged from the hospital too soon.

When you are admitted to the hospital, you have the right to get all the hospital care covered by the Plan that is necessary to diagnose and treat your illness or injury. The day you leave the hospital (your discharge date) is based on when your stay in the hospital is no longer medically necessary. This part explains what to do if you believe that you are being discharged too soon.

 

  • Within two days of admission as an inpatient or during pre-admission, someone at the hospital must give you a notice called the Important Message from Medicare about your rights (call Member Services or 1-800 MEDICARE (1-800-633-4227) to get a sample notice or see it online at http://www.cms.hhs.gov/BNI). This notice explains:

     
    • Your right to get all medically necessary hospital services paid for by the Plan (except for any applicable co-payments or deductibles).
    • Your right to be involved in any decisions that the hospital, your doctor, or anyone else makes about your hospital services and who will pay for them.
    • Your right to get services you need after you leave the hospital.
    • Your right to appeal a discharge decision and have your hospital services paid for by us during the appeal (except for any applicable co-payments or deductibles).
     

    You (or your representative) will be asked to sign the notice to show that you received and understood your rights. Signing the notice does not mean that you agree that the coverage for your services should end – only that you received and understand the notice. If the hospital gives you the notice more than 2 days before your discharge day, it must give you a copy of your signed notice before you are scheduled to be discharged.

  • To get Livanta to review your hospital discharge, you must quickly contact Livanta. The document Important Message from Medicare about your Rights gives the name and telephone number of Livanta and tells you what you must do.

     

    • You must ask Livanta for a “fast review” of your discharge. This “fast review” is also called an “immediate review.”
    • You must request a review from Livanta no later than the day you are scheduled to be discharged from the hospital. If you meet this deadline, you may stay in the hospital after your discharge date without paying for it while you wait to get the decision from Livanta
    • Livanta will look at your medical information provided to Livanta by us and the hospital.
    • During this process you will get a notice, called the Detailed Notice of Discharge, giving the reasons why we believe that your discharge date is medically appropriate. Call Member Services or 1-800-MEDICARE (1-800-633-4227 - TTY users should call 1-877-486-2048) to get a sample notice or see it online at http://www.cms.hhs.gov/BNI/).
    • Livanta will decide, within one day after receiving the medical information it needs, whether it is medically appropriate for you to be discharged on the date that has been set for you.
  • We will continue to cover your hospital stay (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.

  • You will not be responsible for paying the hospital charges until noon of the day after Livanta gives you its decision. However, you could be financially liable for any inpatient hospital services provided after noon of the day after Livanta gives you its decision. You may leave the hospital on or before that time and avoid any possible financial liability.

     

    If you remain in the hospital, you may still ask Livanta to review its first decision if you make the request within 60 days of receiving Livanta’s first denial of your request. However, you could be financially liable for any inpatient hospital services provided after noon of the day after Livanta gave you its first decision.

  • Livanta has 14 days to decide whether to uphold its original decision or agree that you should continue to receive inpatient care. If Livanta agrees that your care should continue, we must pay for or reimburse you for any care you have received since the discharge date on the Important Message from Medicare, and provide you with inpatient care (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.

     

    If Livanta upholds its original decision, you may be able to appeal its decision to an Administrative Law Judge (ALJ). Please see Appeal Level 3 for guidance on the ALJ appeal. If the ALJ upholds the decision, you may also be able to ask for a review by the Medicare Appeals Council (MAC) or a Federal court. If any of these decision makers agree that your stay should continue, we must pay for or reimburse you for any care you have received since the discharge date, and provide you with inpatient care (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.

  • If you do not ask Livanta for a fast review of your discharge by the deadline, you may ask us for a “fast appeal” of your discharge. If you ask us for a fast appeal of your discharge and you stay in the hospital past your discharge date, you may have to pay for the hospital care you receive past your discharge date. Whether you have to pay or not depends on the decision we make.

    • If we decide, based on the fast appeal, that you need to stay in the hospital, we will continue to cover your hospital care (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.

    • If we decide that you should not have stayed in the hospital beyond your discharge date, we will not cover any hospital care you received after the discharge date.

    If we uphold our original decision, we will forward our decision and case file to the Independent Review Entity (IRE) within 24 hours. Please see Appeal Level 2 for guidance on the IRE appeal. If the IRE upholds our decision, you may also be able to ask for a review by an ALJ, MAC, or a Federal court. If any of these decision makers agree that your stay should continue, we must pay for or reimburse you for any care you have received since the discharge date on the notice you got from your provider, and provide you with any services you asked for (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.

Complaints (Appeals) - Skilled Nursing Facility

 

If you think coverage for your skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility services, is ending too soon. When you are a patient in a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF), you have the right to get all the SNF, HHA or CORF care covered by the Plan that is necessary to diagnose and treat your illness or injury. The day we end coverage for your SNF, HHA or CORF services is based on when these services are no longer medically necessary. This part explains what to do if you believe that coverage for your services is ending too soon.

 

  • Your provider will give you written notice called the Notice of Medicare Non-Coverage at least 2 days before coverage for your services ends (call Customer Services or 1-800 MEDICARE (1-800-633-4227) to get a sample notice or see it online at http://www.cms.hhs.gov/BNI/).

    You (or your representative) will be asked to sign and date this notice to show that you received it. Signing the notice does not mean that you agree that coverage for your services should end – only that you received and understood the notice.

  • You have the right to appeal our decision to end coverage for your services. As explained in the notice you get from your provider, you may ask Livanta to do an independent review of whether it is medically appropriate to end coverage for your services. 

  • You must quickly contact Livanta. The written notice you got from your provider gives the name and telephone number of your Livanta and tells you what you must do.

    • If you get the notice 2 days before your coverage ends, you must contact Livanta no later than noon of the day after you get the notice.
    • If you get the notice more than 2 days before your coverage ends, you must make your request no later than noon of the day before the date that your Medicare coverage ends.
  • Livanta will ask why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish. Livanta will also look at your medical information, talk to your doctor, and review information that we have given to Livanta. During this process, you will get a notice called the Detailed Explanation of Non-Coverage giving the reasons why we believe coverage for your services should end. Call Member Services or 1-800-MEDICARE (1-800-633-4227 - TTY users should call 1-877-486-2048) to get a sample notice or see it online at http://www.cms.hhs.gov/BNI/).

    Livanta will make a decision within one full day after it receives all the information it needs.

  • We will continue to cover your SNF, HHA or CORF services (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.

  • You will not be responsible for paying for any SNF, HHA, or CORF services provided before the termination date on the notice you get from your provider. You may stop getting services on or before the date given on the notice and avoid any possible financial liability. If you continue receiving services, you may still ask Livanta to review its first decision if you make the request within 60 days of receiving Livanta’s first denial of your request.

  • Livanta has 14 days to decide whether to uphold its original decision or agree that you should continue to receive services. If Livanta agrees that your services should continue, we must pay for or reimburse you for any care you have received since the termination date on the notice you got from your provider, and provide you with any services you asked for (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.

     

    If Livanta upholds its original decision, you may be able to appeal its decision to an Administrative Law Judge (ALJ). Please see Appeal Level 3 Part 1 for guidance on the ALJ appeal. If the ALJ upholds our decision, you may also be able to ask for a review by the Medicare Appeals Council (MAC) or a Federal Court. If either the MAC or Federal Court agrees that your stay should continue, we must pay for or reimburse you for any care you have received since the termination date on the notice you got from your provider, and provide you with any services you asked for (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.

  • If you do not ask Livanta for a review by the deadline, you may ask us for a fast appeal.
    If you ask us for a fast appeal of your coverage ending and you continue getting services from the SNF, HHA, or CORF, you may have to pay for the care you get after your termination date. Whether you have to pay or not depends on the decision we make.

     

    • If we decide, based on the fast appeal, that coverage for your services should continue, we will continue to cover your SNF, HHA, or CORF services (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described your Evidence of Coverage.

    • If we decide that you should not have continued getting services, we will not cover any services you received after the termination date.

     

    If we uphold our original decision, we will forward our decision and case file to the Independent Review Entity (IRE) within 24 hours. Please see the Appeal Level 2 section above for guidance on the IRE appeal. If the IRE upholds our decision, you may also be able to ask for a review by an ALJ, MAC, or a Federal court. If any of these decision makers agree that your stay should continue, we must pay for or reimburse you for any care you have received since the discharge date on the notice you got from your provider, and provide you with any services you asked for (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.

     

For questions or doubts about this process, call Members Services

Appeals & Grievances - Part D

Each member has the right to file a complaint, grievance or appeal, either directly with the plan or through Medicare. Here we will explain the difference between a complaint or appeal and the process that you must follow when filing with our plan.

 

To file a complaint with Medicare you may call 1-800-Medicare, 24 hours a day, 7 days a week. TTY (hearing impaired) users should call 1-877-486-2048. You may also access the Medicare Complaint Form

 

Plans are expected to disclose grievance, and appeals, upon request, to individuals eligible to elect a Medicare Advantage organization or a Part D Sponsor.  If you are interested in receiving this information, please contact our Member Services Department:

 

MMM

Member Services:

787-620-2397 (Metro Area)

1-866-333-5470 (toll free)

1-866-333-5469 TTY

(hearing impaired)

 

PMC

Member Services:

787-625-2126 (Metro Area)

1-866-516-7700 (toll free)

1-866-516-7701 TTY

(hearing impaired)

 

First+Plus

Member Services:

787-522-7800 (Metro Area)

1-888-767-7717 (toll free)

1-877-672-4242 TTY

(hearing impaired)

 

Monday through Sunday, from 8:00 a.m. to 8:00 p.m.

Grievances​

A grievance is any complaint other than one that involves a coverage determination. You should file a grievance if you have any type of problem with us or one of our network pharmacies that does not relate to coverage for a prescription drug. You must file a grievance, either verbally or in writing, no later than 60 days after the event or incident that precipitates the grievance.

 

Medicare y Mucho Más

Appeals and Grievances
PO BOX 71114 
San Juan, PR 00936-8014

Fax:  787-625-3375

mmm@mmmhc.com

 

PMC Medicare Choice

Appeals and Grievances
PO BOX 366292 
San Juan, PR 00936-6292

Fax:  787-625-3375

pmc@pmc-pr.com

 

First+Plus

Appeals and Grievances
PO BOX 71114
San Juan, PR 00936-8014

Fax:  787-625-3375

mmm@mmmhc.com

 

In certain cases, you have the right to ask for an “expedited grievance,” meaning your grievance will have a resolution within 24 hours. For example, if your complaint involves a refusal to grant a request for an expedited coverage determination or an expedited redetermination and you have not purchased or received the drug in dispute, we must respond to your grievance within 24 hours. If not, we must notify you 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. 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.

 

For more information about Grievances, please refer to Chapter 9 of your Evidence of Coverage.

Appeals

(Reconsiderations or Redeterminations)

 

If we deny any part of your request for coverage or payment or if you disagree with our coverage determination, you may ask us to reconsider our decision. This is called an “appeal” or a “request for reconsideration or redetermination”. If you want to appeal, you must request your appeal within 60 calendar days from the date included on the notice of our coverage determination.

 

Request for Redetermination of Medicare Prescription Drug Denial:

 

MMM Form

PMC Form

First+Plus Form

 

You or someone you name to act on your behalf (your appointed representative) may request an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. You must complete the Appointment of Representative Form.

 

How soon we decide on your appeal depends on the type of appeal. For an expedited (fast) decision about a Part D drug that you have not received, we have up to 72 hours to make a decision. For a claim redetermination we have up to 60 days; for a standard pre service redetermination we have a maximum of 30 days. You or your appointed representative may contact us by telephone or fax at the numbers below:

 

MMM

Member Services:

787-620-2397 (Metro Area)

1-866-333-5470 (toll free)

1-866-333-5469 TTY

(Hearing Impaired)

Fax: 787-620-2390 

 

PMC

Member Services:

787-625-2126 (Metro Area)

1-866-516-7700 (toll free)

1-866-516-7701 TTY

(Hearing Impaired)

Fax: 787-999-9501

 

First+Plus

Member Services:

787-522-7800 (Metro Area)

1-888-767-7717 (toll free)

1-877-672-4242 TTY

(Hearing Impaired)

Fax: 787-620-2390 

 

Monday through Sunday, from 8:00 a.m. to 8:00 p.m.

 

 

If you are notified that a prescription drug has not been approved, and you do not agree, you have the right to ask us to reevaluate your case. You may do so through this website. To protect your privacy and confirm your identity, an MMM representative might contact you, your physician or authorized representative, to ask you for more information or additional documentation.

 

To initiate your request, please press here.

 

For a standard decision, which may include the reimbursement for a Part D drug you already paid for and received, we have up to 7 calendar days to respond. We may answer before that time if it is determined that your health requires us to. You or your appointed representative may mail your written appeal to the following address:

 

Medicare y Mucho Más

Appeals and Grievances
PO BOX 71114 
San Juan, PR 00936-8014

Fax: 787-620-2390

mmm@mmmhc.com

 

PMC Medicare Choice

Appeals and Grievances
PO BOX 366292 
San Juan, PR 00936-6292

Fax: 787-620-2390

pmc@pmc-pr.com
 

First+Plus

Appeals and Grievances
PO BOX 71114
San Juan, PR 00936-8014

Fax: 787-620-2390

mmm@mmmhc.com

 

For more information about how the Appeals Process works, including details of the five levels of the process, please refer to Chapter 9 of the Evidence of Coverage.

 

Non-contracted Providers (Adjustments of Claims and Appeals Rights)

What can I do if payment for my claim was denied by MMM Healthcare, LLC?

 

If MMM Healthcare, LLC denied your payment claim, you have the right to request a claim adjustment within 365 days from the date of service. In addition, you have the right to appeal or dispute payments, according to the corresponding situation. We request that you refer to the Questions and Answers Document to obtain more information and clarify doubts. For your reference, we have attached the different forms to be completed according to your request. We are also providing our mailing address, Fax number and phone number for any submission of information or additional questions you may have.

 

For more information, you can call our Provider Relations Department at 1-866-676-6060, Monday through Friday from 7:00 a.m. to 7:00 p.m.

 

You can also send us a letter by fax at 787-625-3375, email Appeals&GrievanceNotifications@mmmhc.com or by mail to the following address: 

 

For Adjustments in your Claims:

 

Medicare y Mucho Más

Claims Department 
PO BOX 71114 
SAN JUAN PR 00936-8014

 

PMC Medicare Choice

Claims Department  
PO Box 366292 
San Juan PR  00936-6292

 

First+Plus

Claims Department 
PO BOX 71114
SAN JUAN PR 00936-8014

 

 

For Appeals and Grievances:

 

Medicare y Mucho Más

Appeals and Grievances
PO BOX 71114 
SAN JUAN PR 00936-8014

 

PMC Medicare Choice

Appeals and Grievances 
PO Box 366292 
San Juan PR  00936-6292

 

First+Plus

Appeals and Grievances
PO BOX 71114
SAN JUAN PR 00936-8014

 

 

NOTE: If you are an MMM Healthcare, LLC contracted provider, this information is not for you, please refer to the InnovaMD Portal.

Filing a Privacy Complaint

How to file a HIPAA Privacy Complaint?

 

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information, you may file your verbal or written complaint to us:

 

Compliance Department

Privacy Officer

Torre Chardón

350 Ave. Chardón, Suite 500

San Juan, PR 00918-2101

Tel. 787-622-3000

Fax 787-622-7461
  • Through Ethics Point
  • Office for Civil Rights of the United States Department of Health and Human Services at:

 

Office for Civil Rights

U.S. Department of Health and Human Services

Jacob Javits Federal Building

26 Federal Plaza - Suite 3312

New York, NY 10278

Telephone: 800-368-1019

Fax: 202-619-3818

TYY: 800-537-7697

Email: ocrmail@hhs.gov

 

 

We will not retaliate in any way if you choose to file a complaint with us or with the United States Department of Health and Human Services.

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