2. Introduction
1)What a Medicare Part D Grievance is?
2) Why do you file a Medicare Part D Grievance?
3) Who can file a Medicare Part D Grievance
4)How do you File a Medicare Part D Grievance
5) The results of Filing a Medicare Part D Grievance?
3. Overview of Medicare Part D
Medicare Part D covers Drug coverage (Part D)
How to get a drug plan
What drug plans cover
The Cost of the Drug plans
When you can get the Drug plans
4. A Complaint
Any expression of dissatisfaction to a Part D
plan sponsor or provider by an enrollee
made orally or in writing.
5. Grievance
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, regardless of
whether any remedial action can be taken.
7. Example of Grievances
For example, you may file a grievance if you have
a problem calling the plan or if you're unhappy
with the way a staff person at the plan has
behaved towards you.
8. Examples of Grievances
Failure to respect an enrollee's rights. Pharmacy
Copays and the cost of medication.
Refusal to expedite a coverage determination or
appeal. Part D Membership, enrollment, or dues
issues.
9. Examples of Grievances
In addition, grievances may include
complaints regarding the timeliness,
appropriateness, access to, and/or setting
of a provided health service, procedure, or
item.
10. Examples of Grievances
The quality of care or services provided.
Interpersonal aspects of care, such as
rudeness by a provider or staff member.
11. Examples of Grievance
Complaints that a covered health service
procedure or item during a course of
treatment did not meet accepted standards
for delivery of health care
12. Expedited Grievance
An expedited grievance may also
include a complaint that a Medicare
health plan refused to expedite an
organization determination or
reconsideration, or invoked an
extension to an organization
determination or reconsideration time
frame.
13. A complaint about the way your
Medicare health plan or Medicare
drug plan is giving care is a
Grievance?
TRUE
FALSE
15. “I know it's important to do more
than just complain when there's
something you don't like. You need
to try to do something about it, or
you're nothing but a whiner.”
― Jean Ferris, Twice Upon a
Marigold
16. Filing A Grievance
You can file a complaint if you have a concern
about the quality of care or other services you get
from a Medicare provider.
How you file a complaint depends on what your
complaint is about.
17. Filing a Grievance
A complaint could be either a grievance or
an appeal, or a single complaint could
include both.
Every complaint must be handled under
the appropriate grievance or appeal
process.
18. An Appeal
A complaint about a plan's refusal to cover a
service, supply, or prescription,
19. What's the difference between a
Grievance and an Appeal
Grievance
If you have a problem
calling the plan or if
you're unhappy with the
way a staff person at the
plan has behaved towards
you.
Appeal
If you have an issue with a
plan's refusal to cover a
service, supply, or
prescription, you file an
appeal
20. Filing an Appeal
Contact your State Health Insurance Assistance
Program (SHIP) for free personalized help
21. Who Can File?
Grievance requests may be submitted
by a Medicare enrollee, or by a
representative authorized by the
enrollee.
23. Filing a Grievance
Grievances may be filed with the drug plan
orally or in writing within 60 days after the
incident;
24. No one but the enrollee can file
the Grievance
TRUE
FALSE
25. Medicare Complaint Form
You are now able to submit feedback about your
Medicare health plan or prescription drug plan
directly to Medicare using a form on the internet.
The Centers for Medicare & Medicaid Services
values your feedback and will use it to continue
to improve the quality of the Medicare program.
26. Medicare Complaint
If you have any other feedback or concerns,
or if this is an urgent matter, please call 1-
800-MEDICARE (1-800-633-4227). TTY/TTD
users can call 1-877-486-2048.
28. Resolving a Grievance
Plans must resolve within 24 hours a
grievance arising from the plan's decision
not to expedite a coverage determination
or redetermination under the appeals
process.2
30. The Reason to File a Grievance
AMERICAN GREED-The program focuses on
the stories behind some of the biggest
corporate and white collar crimes in recent
U.S. history
31. The Reason to File a Grievance
American Greed-
Michigan doctor Farid Fata pumps poisonous
chemotherapy into cancer-free patients and
pockets $17 million in fraudulent payments.»
Subscribe to CNBC Prime: http://cnb.cx/yt
32. The Reason to File
Skin Doctor Takes His Cut / Revolutionary Guru Of
Greed"
February 4, 2009
Case 1: A respected doctor. Trusting patients. Dr.
Michael Rosin runs a thriving dermatology practice
specializing in a highly effective procedure for
skin cancer. But, Dr. Rosin’s surgery isn’t just a
cancer treatment... it’s a goldmine.[9]
33. The Reason to File a Grievance
It Gives the Enrollee the POWER to bring
attention to problems that are found within
Medical Health Plans or Medical Drug Plans.
38. Conclusion
1)What a Medicare Part D Grievance is?
2) Why do you file a Medicare Part D
Grievance?
3) Who can file a Medicare Part D Grievance
4)How do you File a Medicare Part D
Grievance
4) Conclusion of Filing a Medicare Part D
Grievance?
