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Grievances

A grievance is a type of complaint you make about us or one of our network providers/pharmacies such as problems related to quality of care, waiting time, or the customer service you received. For example, you may file a grievance if you had a problem with the service you received from a provider. A grievance does not involve coverage or payment disputes for medical care or prescription drugs.


Who may file a grievance?

You or your appointed representative may file a grievance. You can name a relative, friend, attorney, doctor, or someone else to act for you. Others may already be authorized under state law to act for you.


Why file a grievance?

You may file a grievance if you have a complaint about the plan you are enrolled in, about a decision the plan has made, or about the quality of care you have received. You may also file a grievance if you have problems getting appointments with a provider or have a complaint about a doctor or pharmacist.


When do I file a grievance?

It is best to file a grievance as soon as you experience a problem you want to complain about. However, your complaint must be filed within 60 days after you had the problem.


How and where to file a grievance?

You can file your grievance in one of two ways:

  • By calling Member Services: This is usually the first step. If there is anything else you need to do, Member Services will let you know. You can reach Member Services at the phone number listed on the back cover of your Evidence of Coverage (or see our Contact Us Page).

  • By writing to us: If you do not wish to call, you can put your complaint in writing and send it to us at the address listed below. If you submit your complaint in writing, we will use our formal procedure for answering your complaint. More information about the formal procedure can be found in Chapter 9, Section 10 of your EOC.

Whether you call or write, you should contact Member Services right away. In most cases, we will try to resolve your complaint over the phone. If you ask for a written response, file a written grievance, your complaint is related to the quality of care you received, or we do not agree with all or part of your complaint, we will respond in writing to you. The longest time we can take to answer your complaint is 30 days. However, we can take up to 14 more days if you ask for more time or if we need information (such as medical records) that may benefit you.


How to file an expedited or fast grievance?

If you would like our plan to use our Expedited/Fast Grievance Process because we denied your request for a "fast coverage decision" or a "fast appeal", or we extended a coverage decision or appeal about your Leon Medical Centers Health Plans Part C medical care, you must contact Member Services. If you have a fast complaint, it means we will give you an answer within 24 hours. For more information about making complaints and the grievance process, see the section on "Making Complaints" in the chapter named "What to do if you have a problem or complaint" in your Evidence of Coverage.


What if I'm still not satisfied with the resolution of the complaint?

If you are not satisfied with the resolution of your complaint you may contact Medicare at 1-800-Medicare (1-800-633-4227). TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week. You can also submit your complaint to Medicare online at https://www.medicare.gov/MedicareComplaintForm/home.aspx


Contact Information for Grievances

CALL

(Main) 305-559-5366
(Toll-free) 1-866-393-5366

Calls to this number are free. Seven days a week from 8:00 am to 8:00 pm

TTY

711

This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

Calls to this number are free. Seven days a week from 8:00 am to 8:00 pm

FAX

305-642-1144

WRITE

8600 NW 41st Street, Suite 201
Doral, FL 33166


If you have questions regarding appeals, exceptions, and/or grievances or if you wish to obtain an aggregate total of appeals/exceptions/grievances filed with the plan, please call Leon Medical Centers Health Plans Member Services, 8 a.m. to 8 p.m., 7 days a week, toll free at 1-866-393-5366. TTY/TDD users call 711.