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Grievances and Appeals
IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS
For more information about your appeal rights, call us or see your Evidence of Coverage.
- What Is A Grievance?
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 D drugs, 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.
- Filing A Grievance With Our Plan
If you have a complaint, you or your representative may call 1-888-858-8551 5 a.m. to 5 p.m. Monday through Friday PST, TTY/TDD 1-888-858-8567. This number requires special telephone equipment. 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 our grievance procedure. As an enrollee of a Sterling Health Plan, if your complaint is received by telephone, Sterling will attempt to address and resolve your complaint by telephone, especially if your complaint involves a possible misunderstanding or misinformation. If you request a written response to your phone complaint, we will respond in writing to you.
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.
- What If I Don’t Agree With A Decision?
You have the right to appeal. To exercise it, file your appeal in writing within 60 calendar days after the date of this notice. We can give you more time if you have a good reason for missing the deadline.
- Who May File An Appeal?
You or someone you name to act for you (your authorized representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others also already may be authorized under State law to act for you.
You can click here to learn how to name your authorized representative or call us at 1-888-858-8551. If you have a hearing or speech impairment, please call us at TTY/TDD 1-888-858-8567. If you want someone to act for you, you and your authorized representative must sign, date and send us a statement naming that person to act for you.
- How Do I File An Appeal?
You or your authorized representative should mail or deliver your written and signed appeal to the addresses below:
Medicare Advantage Appeals
Sterling Life Insurance Co.
Attn: Appeals & Grievance Department
P.O. Box 1917
Bellingham, WA 98227-1917
OR Email us at: appeal@sterlingplans.com
OR Fax us at: 1-888-858-8552
OR Website: http://www.sterlingplans.com
We must give you a decision no later than 60 calendar days after we receive your appeal.
Part D Appeals:
Express Script Inc,
Attn: Pharmacy Appeals - Part D
Mail Route: BL0390
6625 West 78th Street
Bloomington, MN 55429
OR Fax us at: 1-877-852-4070
We must give you a decision no later than 14 calendar days after we receive your appeal.
- What Do I Include With My Appeal?
You should include: your name, address, Member ID number, signature, reasons for appealing, and any evidence you wish to attach.
You may send in supporting medical records, doctors’ letters, or other information that explains why we should pay for the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.
- What Happens Next?
If you appeal, we will review our decision. After we review our decision, if payment for any of your claims is still denied, Medicare will provide you with a new and impartial review of your case by a reviewer outside of your Medicare Advantage Organization. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.
- Contact Information:
If you need information or help, call us at:
Toll Free: 1-888-858-8551
TTY/TDD: 1-888-858-8567
- Other Resources To Help You:
Medicare Rights Center
Toll Free: 1-888-HMO-9050
Elder Care Locator
Toll Free: 1-800-677-1116
1-800-MEDICARE (1-800-633-4227)
TTY/TDD: 1-877-486-2048
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