Grievances & Appeals

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.” It is a formal complaint or dispute you have with Martin’s Point or one of our plan providers.

There could be many reasons, 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.

You or your authorized representative may file a formal grievance either verbally or in writing by contacting our Member Services Department or mailing your request to Martin’s Point.

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.

Generations Advantage members may mail your written grievance to:

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

If your request for a fast appeal (sometimes called, an “expedited organization determination” or “expedited reconsideration”) is denied by Martin’s Point Generations Advantage, you have the right to submit a fast grievance request.

If you file a fast grievance, our Grievance Coordinator will respond to your request within 24 hours.

The parties who may request a standard or expedited redetermination include an enrollee, an enrollee’s representative, or an enrollee's prescribing physician or other prescriber. 

If you are appointing a representative, the Medicare Appointment of Representative form is required to be sent in with the appeal.

Requesting an Appeal from Martin's Point Generations Advantage

As a Martin’s Point Generations Advantage member, you have the right to ask us to reconsider our decisions. An appeal is a formal complaint or dispute regarding our decision not to pay for, not to provide, or to stop paying for or providing an item or service that you believe is needed. When you file an appeal, you are asking us to reconsider and change an initial decision (also called an initial organization determination) we have made about what services we will cover for you.

An appeal can also be called a “request for reconsideration.”

The appeals process would apply in situations such as:

• 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.

If you file a standard appeal request for care or treatment that you have not yet received, it will be processed within 30 calendar days of receiving your appeal. However, if your request is for a decision about care that you have already received, your appeal request will be processed within 65 calendar days of receiving your request. If either you or we find that some information is missing which can help you, we can take up to 14 more calendar days to make our decision. 

As a member of Martin’s Point Generations Advantage, you can generally appeal our decision not to cover a drug, vaccine, or other Part D benefit.

You may also appeal our decision not to reimburse the payment for a Part D drug. In addition, if you think we should have paid or reimbursed more than you received, or the amount paid is more than you are supposed to pay under the plan, you can appeal. Finally, if we deny an exception request, you can appeal.

There are five levels to the appeals process for Martin’s Point Generations Advantage members. At each level, the request for Part D benefits or payment is considered and a decision is made. The decision may be partly or completely in your favor (giving some or all of what you asked for), or it may be completely denied (turned down). If you are unhappy with the decision, there may be another step to get further review of the request.

Whether you can take the next step may depend on the dollar value of the requested drug or on other factors.

When making an appeal the first level of appeal is with the plan. We review the coverage decision we have made to check to see if we are following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. 

If we say no to all or part of your Level 1 appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to us. (In some situations, your case will be automatically sent to the independent organization for a Level 2 Appeal. If this happens, we will let you know. In other situations, you will need to ask for a Level 2 Appeal.)

If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal. Whether you can take the next step may depend on the dollar value of the requested service.

Who Can Request an Appeal?

The parties who may request a standard or expedited redetermination include an enrollee, an enrollee’s representative, or an enrollee's prescribing physician or other prescriber.  If you are appointing a representative, the Medicare Appointment of Representative form (PDF)is required to be sent in with the appeal.

How Do I Request an Appeal?

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.  You must request your appeal no later than 65 days following our original denial of coverage unless you have good cause for us to open a case beyond 65 days.  Some good cause reasons include a serious illness that would have prevented you from filing on time, death or serious illness in your immediate family, an accident that caused your records to be destroyed, among others. 

Generations Advantage Members can mail your request to us at:

Martin’s Point Generations Advantage Appeals Department
P.O. Box 8832
Portland, ME 04104-9861
Fax: 207-828-7874

US Family Health Plan Members can mail your request to us at:

Martin’s Point US Family Health Plan Appeals Department
P.O. Box 8832
Portland, ME 04104-9861
Fax: 207-828-7849

 

An enrollee, enrollee’s representative or enrollee’s prescribing physician or other prescriber may request a standard redetermination by filing a written request with the Part D plan sponsor. 

The request must be filed within 65 calendar days from the date printed or written on the written coverage determination denial notice.

The request may be verbal, by calling our office, or in writing by mailing it to:

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

You may also fax the request to 1-855-633-7673

You can also use our Redetermination form (PDF).  You are not required to use this form but it may be a helpful guide.

You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 30 days for a decision. If your request to expedite is granted, we must give you a decision no later than 72 hours after we get your physician’s supporting statement.

For more information about expedited appeals, please call the Generations Advantage Member Services team.

You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to seven days for a decision. If your request to expedite is granted, we must give you a decision no later than 72 hours after we get your prescribing physician’s supporting statement.

For more information about expedited appeals call 1-888-296-6961 (TTY: 711).

We must provide written notice of your redetermination (appeal), whether favorable or adverse, as expeditiously as the enrollee’s 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.