Part C Organization Determinations, Appeals & Grievances

Organization Determination

An organization determination is a decision (approval or denial) HealthTeam Advantage makes regarding payment or benefits to which you believe you are entitled under Medicare Part C. An organization determination would involve these types of benefits:

• Out of the area renal dialysis services
• Payment for any other health services furnished by a provider
• Discontinuation of a service if you believe that continuation of the services is medically necessary.

How to request an organization determination

You, your appointed representative or your physician may request an organization determination. You or your appointed representatives can call, fax or mail in a request for an organization determination. However, the preferred method is to have your prescribing physician call HealthTeam Advantage with a supporting statement for your request. It is recommended but not required to have your doctor provide a supporting statement for your request.

To file your request, please use the following contact information:

Phone: 1-888-965-1965 / TTY: 711 / Fax: 845-4104

Mail: HealthTeam Advantage
Attn: Member Concierge
300 E. Wendover Ave. Suite 121
Greensboro, NC 27401

For more information regarding Part C Appeals and Grievances, please see Chapter 2 and Chapter 9 of your Evidence of Coverage.

What is an Appeal?

An appeal is a request you make if you disagree with our decision to deny an authorization request for services to be received (Pre-Service), discontinue or stop services being received, deny services already received (Claims), or if you disagree with the amount of copayment or coinsurance you are required to pay for services already received (Claims).

Standard Appeals must be requested in writing.

Appeals for denials of services to be received (Pre-Service) will be responded to within 30 calendar days from the date we receive the request. This timeframe may be extended with an addition of 14 calendar days if you request an extension or if we justify the need for additional time is in your best interest. We will provide you with a written notification if an extension is taken.

You, your authorized representative, or your physician may request this type of appeal.

Appeal requests for denials of services already received (Claims) or appeal requests for the amount of copayment or coinsurance being charged (Claims), will be responded to within 60 calendar days from the date we receive the request. These appeal requests cannot be expedited.

You or your authorized representative may request this type of appeal.

Expedited or “Fast” Appeals can be requested verbally or in writing.

If we have denied an authorization for services to be received or a decision has been made to discontinued or stop services being received, you, your authorized representative, or your physician may request an expedited (fast) appeal.

For appeals regarding the An Important Message From Medicare About Your Rights, please follow the instructions in this notice to file an appeal.

For appeals regarding the Notice of Medicare Non-Coverage, please follow the instructions in this notice to file an appeal.

What is a Grievance?

A grievance is any compliant or dispute, other than one that involves an organization determination decision for services or payment, which expresses dissatisfaction with the manner in which HealthTeam Advantage provides health care services or one of our contracted providers.

Examples of grievance issues can include, but not are not limited to, issues related to quality of care, waiting times, and the customer service you receive.

Grievances may be requested verbally or in writing. A written response will be provided to all grievances received in writing.

Standard Grievances will be responded to within 30 calendar days from the date we receive the request. This timeframe may be extended with an addition of 14 calendar days if you request an extension or if we justify the need for additional time is in your best interest. We will provide you with a written notification if an extension is taken.

Expedited or “Fast” grievances can be requested if we have denied your request for an expedited organization determination, an expedited appeal, or if we have taken an extension on an organization determination or an appeal. Expedited or “Fast” grievances will be responded to within 24 hours of when we receive the request.

When can I file an Appeal or Grievance?

You must request an appeal or a grievance within 60 calendar days from the date of denial or the date of the event that led to the dissatisfaction. A specific form is not required to file an appeal or a grievance. 

Who can request an Appeal or a Grievance?

You or your appointed representative may file an appeal or a grievance. You may appoint an individual to act as your representative by filing out and submitting an Appointment of Representative (AOR) form, or other legal papers granting authority to act on your behalf.

Your Physician may also request certain types of appeals on your behalf. See the “Appeals” section above for more information.

An appeal or a grievance request, by someone other than you, is not valid until the appropriate documentation is received by HealthTeam Advantage. We cannot begin or complete our review until we receive the appropriate documentation.

To allow someone to become your authorized representative, you may download and complete the Appointment of Representative form  and submit to HealthTeam Advantage.

How do I request an Appeal or a Grievance?

To request a verbal grievance or an expedited appeal, call your HealthTeam Advantage Healthcare Concierge department from October 1 – March 31, 8 a.m. to 8 p.m. ET, seven days a week or April 1 – September 30, 8 a.m. to 8 p.m. ET, Monday through Friday, at this number:

Phone: 1-888-965-1965 / TTY: 711

If you’d like to file a written grievance or appeal, please send it to:

Mail: HealthTeam Advantage
Attn: Appeals and Grievances
300 E. Wendover Ave. Suite 121
Greensboro, NC 27401

Fax: 800-845-4104