Grievances & Appeals

At Martin’s Point, we are committed to providing our members a fair and timely process for resolving any complaints or disputes.

As a Martin’s Point plan member, you have a right to file a complaint if you think you aren’t getting quality service from us or you have quality of care issues with a plan provider. This type of complaint is called a “grievance"—a formal complaint or dispute you have with Martin’s Point or one of our plan providers.

Additionally, members have the right to appeal coverage decisions for medical services and prescription drug coverage.

We encourage Martin’s Point plan members to contact us with questions, concerns, or problems related to any benefits or service. Please call us at 1-866-544-7504 (TTY: 711), 8 am to 8 pm, seven days a week from October 1–March 31, and Monday through Friday the rest of the year, to discuss your concerns. Additional information about filing a grievance or appeal is available below.

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If you’re unhappy with a service, provider experience, or any aspect of your care, you have the right to file a grievance. It’s your way to let us know something didn’t go as expected. We take your concerns seriously and will investigate and respond.

There could be many reasons to file a grievance, such as:

• A problem with the quality or timeliness of services you receive

• A problem with how and when you were enrolled in or disenrolled from the plan

• Difficulty getting through on the telephone

• A complaint about the cleanliness or condition of the doctor’s office or pharmacy.

Filing a grievance

You may file a formal grievance either verbally or in writing by contacting our Member Services Department or mailing your request to Martin’s Point. If you prefer to have someone act on your behalf, you can appoint an authorized representative to help you with your grievance or request.

Generations Advantage members who wish to appoint a representative may use the official form below:
Medicare Appointment of Representative (AOR) Form [PDF]

Generations Advantage Grievances

File via Phone: To file a grievance verbally, please call us at 1-866-544-7504  (TTY: 711). 

We are available 8 am–8 pm, seven days a week from October 1 to March 31; and Monday through Friday the rest of the year.

File via Mail: Send written grievances to the following address:

Martin’s Point Generations Advantage, Grievance Department
PO Box 9746
Portland, ME 04104-5040

US Family Health Plan Grievances

File via Phone: To file a grievance verbally, please call us at 1-888-396-2714 (TTY: 711). 

We are available 8 am–8 pm, seven days a week from October 1 to March 31; and Monday through Friday the rest of the year.

File via Mail: Send written grievances to the following address:

Martin’s Point US Family Health Plan, Grievance Department
PO Box 9746
Portland, ME 04104-5040

Generations Advantage members may file a complaint directly with Medicare
If your complaint is about your Medicare health plan or drug plan—for example, service issues, coverage concerns, or delays—you may file a complaint directly with Medicare using the official Medicare Complaint Form:
https://www.medicare.gov/my/medicare-complaint

Note: If your concern involves discrimination or a failure to provide required language or disability assistance, please visit our Notice of Nondiscrimination page for information on how to file a civil rights complaint.

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As a Martin's Point health plan member, you have the option to appeal our decision not to cover a service, drug, vaccine, or other benefit. If a service or claim is denied and you disagree with the decision, you have the right to appeal. An appeal (also called a "request for reconsideration") is a formal request for us to review and reconsider a decision we’ve made about your coverage. If instead you want to submit a complaint about your Medicare plan or service experience, you may use the Medicare Complaint Form available at https://www.medicare.gov/my/medicare-complaint.

• The plan denies payment for services you believed to be an emergency or urgent.

• Either the plan or a plan medical provider refuses to provide services to you that you believe should be provided, arranged, or paid for by the plan.

• The plan refuses to pay for any basic benefit for any reason, including medical necessity.

• Either the plan or a plan medical provider decides to stop or reduce coverage for a treatment or service you have been getting, and you feel that this decision could harm your health.

The parties who may request an appeal or redetermination include an enrollee, an enrollee’s representative (such as a family member), or an enrollee’s prescribing physician or other prescriber. If you are appointing a representative, the required form depends on your health plan: 

Generations Advantage members: Medicare Appointment of Representative (AOR) Form [PDF]

US Family Health Plan members: Appeals Authorization Representative Form [PDF]

Martin’s Point US Family Health Plan, Appeals
PO Box 8832
Portland, ME 04104-5040

Request an appeal

To start an appeal, submit a fax or written request. Appeals must be submitted within 90 days of the denial notice. We will review your case and send you a decision by mail. You can also authorize someone else, such as a provider or family member, to file an appeal for you.

Your appeal must be made in writing. Simply mail or fax us a letter indicating what it is you would like to appeal, along with any documents that support your appeal, such as a copy of a bill you are receiving, medical records, or pictures of your injury.

Generations Advantage (Part C) Appeals

Generations Advantage members can mail or fax appeal requests for medical services and benefits (Part C) to us at:

Martin’s Point Generations Advantage, Appeals
PO Box 8832
Portland, ME 04104-5040

Fax: 207-828-7874

US Family Health Plan Appeals

US Family Health Plan members can mail or fax appeal requests to us at:

Martin’s Point US Family Health Plan, Appeals
PO Box 8832
Portland, ME 04104-5040

Fax: 207-828-7849

Prescription drug appeals

Generations Advantage (Medicare Part D): If your appeal is related to a Medicare Part D prescription drug, you can call CVS Caremark at 1-888-296-6961 or jump to the Prescription Drug (Part D) Appeals section below.

US Family Health Plan: For information about prior authorizations, coverage decisions, and how to appeal a prescription drug for US Family Health Plan, visit Prior Authorizations and Prescription Drug Appeals.

Additional appeals information for Medicare Advantage medical services (Part C)

For more details about Medicare Advantage Part C medical services appeals, review the information below.

Prescription drug appeals for Generations Advantage members are handled separately from medical service appeals. Medicare Part D prescription drug coverage is administered by CVS Caremark.

Requests related to Part D prescription drug coverage begin with a coverage determination. If you do not agree with the initial coverage determination, you may request a redetermination (appeal)—also called an “adverse coverage determination”. 

You may appeal decisions related to Medicare Part D prescription drug coverage, including denials of coverage, reimbursement decisions, payment amounts, or denied exception requests.

For questions or assistance with prescription drug coverage determinations or appeals, you may contact CVS Caremark at 1-888-296-6961.

Generations Advantage Prescription Drug (Part D) Appeals

Requests for Medicare prescription drug coverage determinations and redeterminations (appeals) may be submitted verbally by phone or in writing by mail or fax to the address below:

CVS Caremark – Martin’s Point Generations Advantage
Appeals Department
MC109
PO Box 52000
Phoenix, AZ 85072-2000

Fax: 1-855-633-7673

Important timeframes:

• Coverage determination: Decisions are generally provided within 72 hours, or within 24 hours if expedited.
• Requesting an appeal: You have 65 calendar days from the date printed or written on the coverage determination denial notice to request a redetermination. 
• Appeal decision (redetermination): We must provide written notice of your redetermination (appeal), whether favorable or adverse, as expeditiously as your health condition requires, but no later than 7 calendar days from the date the Part D plan sponsor receives the request for a standard redetermination, or within 72 hours if an expedited review is approved.

There are multiple levels to the Part D appeals process. If you do not agree with a decision, additional levels of review may be available based on the circumstances of your request.

Learn more:

Find instructions for submitting Part D coverage determinations and appeals, including forms, online options, and expedited requests.

Coverage Determination and Appeals