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Member Grievances & Appeals

Understanding the member process.

Providers play an important role in supporting Martin’s Point members through grievance and appeal requests. Submission pathways vary by health plan and request type.

Generations Advantage medical appeals are processed by Martin’s Point. Medicare Part D prescription drug determinations and appeals for Generations Advantage are administered by CVS Caremark. US Family Health Plan grievances and appeals are processed by Martin’s Point.

Follow the plan-specific guidance below and include required authorization documentation when acting on behalf of a member.

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Grievance Submission Appeal Submission Prescription Appeal Submission Plan Handbooks


Grievance Submissions

What is a grievance?

A grievance is a complaint about service, access, or interactions with the plan or its administrators. Complaints about coverage denials for services, supplies, or prescriptions are handled as appeals.

Medicare icon 
Generations Advantage Grievances

File via Phone:

Providers assisting a member should direct the member to call Member Services 1-866-544-7504 (TTY: 711). Providers with questions about submitting on behalf of a member should contact the Provider Inquiry (PI) line: 1-888-732-7364.

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

File via Mail: 

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

 Authorization form:

Medicare Appointment of Representative (AOR) Form [PDF]

 

military icon
US Family Health Plan Grievances

File via Phone:

Providers assisting a member should direct the member to call Member Services 1-888-674-8734 (TTY: 711). Providers with questions about submitting on behalf of a member should contact the Provider Inquiry (PI) line: 1-888-732-7364.

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

File via Mail: 

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

Generations Advantage (Medicare) resources:

If a concern cannot be resolved through the plan’s grievance or appeals process, members may file a complaint directly with Medicare using the Medicare Complaint Form.

The Office of the Medicare Ombudsman also assists with complaints and grievance concerns. 

US Family Health Plan (TRICARE) resources:

For grievance information, refer to the TRICARE Grievance page.

Appeal Submissions

Providers may submit an appeal on behalf of a Martin’s Point member when authorized to do so. An appeal is a formal request to reconsider a coverage or payment decision, including determinations not to pay for, not to provide, or to discontinue an item or service believed to be medically necessary.

Common appeal scenarios include:

  • Denial of payment for services determined to be emergency or urgent.
  • Refusal to provide, arrange, or pay for services believed to be covered.
  • Denial of coverage based on medical necessity.
  • Reduction or termination of an approved treatment or service.

Appeal review timeframes and submission criteria vary by health plan. Refer to plan-specific guidance below when submitting on behalf of a member.

Appeal requests may be filed by the member, an authorized representative, or the prescribing physician or treating provider. Include applicable authorization documentation when required for the applicable plan.

Submit an appeal

Appeals must be submitted in writing and include supporting documentation (e.g., medical records, clinical rationale, billing statements).

Generations Advantage (Medicare):

Standard appeal requests for services not yet received (pre-service) are generally processed within 30 calendar days of receipt. Appeals related to services already received (post-service) are processed within 65 calendar days. If additional information is required, the review timeframe may be extended by up to 14 calendar days.

Providers assisting a member should direct them to Member Services at 1-866-544-7504 (TTY: 711). For provider submission questions, contact the Provider Inquiry (PI) line at 1-888-732-7364.

US Family Health Plan (TRICARE):

Appeals may be submitted following a denied authorization or service determination. Standard appeals must be submitted within 90 days of the denial notice. Expedited appeals may be requested when waiting for a standard decision timeframe could seriously jeopardize the member’s health.

Providers assisting a member should direct them to Member Services at 1-888-674-8734 (TTY: 711). For provider submission questions, contact the Provider Inquiry (PI) line at 1-888-732-7364.

Medicare icon 
Generations Advantage Appeals

Mail appeal requests on behalf of a members to:

Medical Appeals (Medicare Part C)

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

Fax: 207-828-7874

Prescription Drug Appeals (Medicare Part D)

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

 

Fax: 1-855-633-7673

 

 Authorization form:

Medicare Appointment of Representative (AOR) Form [PDF]

 

military icon
US Family Health Plan Appeals

Mail appeal requests on behalf of a members to:

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

Fax: 207-828-7849

 Authorization form:

  Appeals Authorization Representative Form [PDF]


For pharmacy prior authorizations, coverage decisions, and prescription drug appeals, visit Prior Authorizations and Prescription Drug Appeals.

Expedited Appeal Requests

Expedited (fast) appeal requests may be submitted when waiting for a standard review timeframe could seriously jeopardize the member’s life, health, or ability to regain maximum function.

Requests must include supporting clinical documentation or a physician statement indicating the need for expedited review.

When approved, expedited appeal decisions are generally issued within 72 hours of receipt.

Generations Advantage (Medicare):
Submit expedited appeal requests by phone or fax:
Phone: 1-855-344-0930 (24 hours a day, 7 days a week)
Fax: 1-855-633-7673

US Family Health Plan (TRICARE):
Expedited appeals may be requested when urgent clinical circumstances apply. Submit requests with supporting documentation through standard appeals submission channels (phone or fax) for plan review.

Generations Advantage Medicare Part D Appeals

Medicare Part D coverage determinations (initial requests) and redeterminations (appeals) for Generations Advantage are administered separately from medical service appeals.

Requests may be submitted by the member, prescribing provider, or authorized representative through the following channels:

Authorization requirements: Prescribers may submit coverage determinations without an Appointment of Representative (AOR) form. An AOR form is required when submitting a redetermination (appeal) on behalf of a member as their authorized representative.

If the request is denied: If the initial decision is to deny coverage (an “adverse coverage determination”), the member may request a redetermination (Appeal Level 1). Redeterminations must be requested within 65 calendar days from the date on the denial notice.

Include your reason for appealing: Explain why you disagree with the denial and attach supporting information when available. Clinical information may be provided by the prescriber.

Important timeframes:

  • Coverage determination: Decisions are generally provided within 72 hours, or within 24 hours if expedited.
  • Requesting an appeal (redetermination): Must be requested within 65 calendar days from the date printed or written on the coverage determination denial notice.
  • Appeal decision (redetermination): Written notice of the redetermination (appeal), whether favorable or adverse, will be provided as expeditiously as the member’s health condition requires, but no later than 7 calendar days from receipt of a standard redetermination request, or within 72 hours if expedited.

Plan Handbooks

For more details on the Grievance and Appeals process for each plan, please refer to the member plan handbooks:
 
Generations Advantage Handbook
Access additional information about Martin's Point Generations Advantage plans.
US Family Health Plan Handbook
Access additional information about the US Family Health Plan.

Plan Handbooks

If you ever have any issues with your Generations Advantage plan, we hope you will let us know so we can help.

To File a Complaint with Martin's Point Generations Advantage:

Call Member Services 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. 

Fax a written complaint to 207-828-7874.

You may also mail your complaint to:

Martin's Point Generations Advantage
ATTN: Member Services - Grievances
PO Box 9746
Portland, ME 04101-5040

If you suspect fraud, waste or abuse, please call the Martin's Point Compliance Hotline at: 1-800-297-8616.

 

Medicare Complaint Form

You can submit a complaint directly to Medicare if you’d like by filling out the Medicare Complaint Form. 


Medicare Website

To visit Medicare’s official website, which includes the Medicare and You handbook and ratings of all Medicare health plans, visit www.Medicare.gov 


Medicare Ombudsman

The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests. Visit the Medicare Ombudsman website

As a Martin’s Point Generations Advantage 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 Generations Advantage 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.

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. 

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.

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. 

Please fax your request to us at: 207-828-7874.

Please mail your request to us at:

Martin’s Point Generations Advantage Appeals Department
P.O. Box 8832
Portland, ME 04104-9861

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 made verbally by calling CVS Caremark at 1-888-296-6961, 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 submit your request online.

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 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).

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.

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.
To get more information on your plan and benefits, please see the Evidence of Coverage document on the Plan Documents page.


Provider Manual content reviewed and updated as of January 1, 2026.