MCS Classicare Procedure for Handling Part D Grievance

What is a Part D Grievance?

A grievance is any complaint, other than one that involves a coverage determination, a Low-Income Subsidy (LIS) or Late Enrollment Penalty (LEP) determination, expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. A grievance may also include a complaint that a Part D plan sponsor refused to expedite a coverage determination or re-determination. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item.

What types of problems might lead you filling a grievance?

• Waiting too long for prescriptions to be filled
• Difficulty with the services you receive in Member Services
• Problems with the quality of care or benefits you receive
• Interpersonal aspects of care, such as rudeness by a pharmacist or staff member.
• A plan's benefit design
• A plan sponsor's failure to issue a decision in a timely manner
• A plan sponsor's denial of an enrollee's request for an expedited coverage determination or expedited re-determination.
• If you disagree with our decision not to give you a fast coverage determination or redetermination.

If you have one of these types of problems and want to make a complaint, it is called “filling a grievance.”

Who may file a grievance?

You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call Member Services at 1-866-627-8183 or TTY 1-866-627-8182 (Telephone for persons with hearing or speech impairment). From October 1st through March 31st, you can call us, 7 days of the week, from 8:00 a.m. to 8:00 p.m. From April 1st through September 30, you can call us Monday through Friday, from 8:00 a.m. to 8:00 p.m., and Saturday, from 8:00 a.m. through 4:30 p.m. You may also fill out an Appointment of Representative and submit it along with your claim.

MCS Classicare will confirm that the person filling the grievance is the authorized representative. If we cannot confirm this, we will send a letter to you requesting the Appointment of Representative Form and establishing that the timeframe for acting on a grievance commences when the documentation is received. If we do not receive the documentation by the conclusion of the grievance timeframe, we will notify you about the dismissal of your case.

Availability of Assistance to File a Grievance

To ensure that the grievance procedure is accessible to all members and is provide in a culturally competent manner, including those with limited English or Spanish proficiency or reading skills, and those with diverse cultural and ethnic backgrounds, MCS Classicare will provide the following services when necessary:

• TTY Line (the number for the hearing impaired, 1-866-627-8182) 
• Sign Language and/or Foreign Language Interpreter and Written Translation Services
• Audio Tapes
• Braille
• Language Line Service, Inc.

Filling a grievance with our Plan

If you have a complaint, both you and your representative may call us at 1-866-627-8183 or TTY 1-866-627-8182 (the number for the hearing impaired) From October 1st through March 31st, you can call us, 7 days of the week, from 8:00 a.m. to 8:00 p.m. From April 1st through September 30, you can call us Monday through Friday, from 8:00 a.m. to 8:00 p.m., and Saturday, from 8:00 a.m. through 4:30 p.m. We will try to resolve your complaint by phone. If you request a response in writing, file a complaint in writing, or if your complaint is regarding the quality of care, we will respond to you in writing. If we are unable to resolve your complaint by telephone, we have a formal procedure for reviewing your complaints. We call this the grievance procedure. You may file a grievance in writing by sending it via fax at 787-620-7765 , by delivering it in person at one of our Service Centers, or by mailing in your request to MCS Advantage, Inc., Department of Grievances and Appeals, PO Box 195429, San Juan, PR 00919-5429.

The grievance must be submitted within 60 days of the event or incident. For Dual Eligible enrollees (Medicare and Medicaid), grievance can be submitted at any time. 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.

Fast Grievances

In some cases, you are entitled to request for a “fast grievance,” which means that we will answer your grievance in 24 hours. You may file a fast grievance and our Plan will have to respond within 24 hours of your request, if our Plan extends the period for making a coverage determination or redetermination. You may also file a fast grievance and our Plan will have to respond within 24 hours of your request, if our Plan does not grant the expedited request for the coverage determination or redetermination.

For Quality of Care issues, you have the right to file a grievance before the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)

Quality of Care grievances may be received and acted upon by the Plan, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), or both. For any grievance submitted to the BFCC-QIO, we must cooperate with the BFCC-QIO in resolving the grievance.

In Puerto Rico, the contracted organization is Livanta. You or your Authorized Representative can contact Livanta by phone or in writing:

Livanta LLC
BFCC-QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701-1105
Local telephone number: 787-520-5743
Toll free number: 1- 866-815-5440
Fax number: (855) 236-2423
TTY (for people with hearing disabilities): 1- 866-868-2289
Voicemail: 24-hour voicemail service is available
Working Hours: Monday to Friday, 9:00 am to 5:00 pm

https://livantaqio.com/en

Other Rights for Dual Eligible Enrollees (Medicare and Medicaid)

You have the right to file a grievance in the Patient Advocate Office of Puerto Rico Government by calling: (787) 977-0909, 1-800-981-0031 (free of charge), TTY (787) 710-7057 or via fax (787) 977-0915.