Grievances & Appeals

A grievance is a type of complaint a member can make that does not usually involve coverage or payment for services. Members or their authorized representatives can file a grievance when they have a problem with the quality of their medical care, wait times, or the quality of customer service they received. Members can also file a grievance if they feel like Neighborhood has not responded quickly enough to a request for coverage determination or organization determination, or to an appeal.

Neighborhood responds to member grievances within 30 calendar days.

A member or a member’s representative can file a grievance by calling Neighborhood Member Services at 1-844-812-6896 (TTY 711), 8:00 a.m. to 8:00 p.m., seven days a week from October 1 through March 31. From April 1 through September 30, you can call us 8:00 a.m. to 8:00 p.m. Monday through Friday. You may leave a voicemail on Saturdays, Sundays, and federal holidays. The call is free.

Members can also submit a grievance in writing or in person.

All grievances submitted should include:

• The member’s name and address
• Their Neighborhood member ID number
• A summary of why the member is unhappy

To submit a grievance to Neighborhood, send your request:

By mail: Neighborhood Health Plan of Rhode Island
Grievances and Appeals Department
910 Douglas Pike
Smithfield, RI 02917

By fax: 1-401-709-7005

You can also submit a grievance directly to Medicare by visiting Medicare.gov or by calling  1-800-Medicare (TTY 1-877-486-2048). Calls to this number are free, 24 hours a day, 7 days a week.

An appeal is a type of complaint that a member can make when they want to ask for the reconsideration of a decision that was made regarding a service, or the amount of payment Neighborhood pays or will pay for a service, or the amount the member must pay for a service.

There are 2 kinds of appeals:

• Standard Appeal 

Neighborhood will provide a written decision on a standard appeal within 30 calendar days after the appeal is received (or within 7 calendar days for an appeal related to a Medicare Part B prescription drug).

Neighborhood’s decision for a standard appeal might take longer however if a member asks for an extension, or if we need more information about the case. If this happens, Neighborhood will let the member know why more time is needed.

If an appeal is for payment of a service that the member has already received, a written decision will be provided within 30 calendar days.

• Fast (Expedited) Appeal

Neighborhood provides decisions on fast appeals within 72 hours after the appeal is received. Members can ask for a fast appeal if they or their provider believes the member’s health could be seriously harmed if they need to wait for 30 days for a decision.

Neighborhood automatically processes fast appeals when a provider asks for one on behalf of the member or if that provider agrees with the member’s request. If a member asks for a fast appeal without the support of a provider, Neighborhood will decide if the request requires a fast appeal. Without a fast appeal, a decision is made within 30 calendar days (or within 7 calendar days if the appeal is for a Medicare Part B prescription drug).

Standard Part D Appeals

• Members have the right to appeal if they do not agree with a decision Neighborhood makes about a prescription drug covered by Medicare. A written decision on a standard Part D appeal will be made within 7 calendar days after the appeal is received.
• If the appeal is for payment of a drug the member has already received and has gotten a denial for, Neighborhood will provide a written decision within 14 calendar days. Please note, these payment requests cannot be expedited.

Fast (Expedited) Part D Appeals

• Sometimes waiting 7 days for a coverage decision related to a prescription drug could seriously affect a person’s health. If a member or a member’s provider believes that member’s request has to be reviewed quickly, they can ask for a fast or “expedited” appeal. Neighborhood provides a decision on expedited appeals within 72 hours after the appeal is received.
• To ask for an expedited appeal, call Member Services at 1-844-812-6896 (TTY 711).
• If the prescribing provider asks for an expedited appeal or supports the member’s request and informs us that waiting 7 calendar days could seriously harm the member’s health, Neighborhood will automatically expedite the appeal.
• If the request is made without support from the prescriber, Neighborhood will decide if the health of the member requires an expedited appeal. Neighborhood will notify the member if an expedited appeal is not required and will decide the appeal within 7 days.
• To ask for a Part D (Prescription Drug) appeal, call, mail, or fax your request to:

CVS Caremark Part D Appeals and Exceptions
PO BOX 52000 MC109
Phoenix, AZ 85072-2000

Phone: 1-844-812-6896
Fax: 1-855-633-7673

• To ask for reimbursement for a Part D prescription that was paid for out-of-pocket, please mail or fax a copy of your receipt and related prescription documents to:

CVS Caremark Part D Claims Processing
PO BOX 52066
Phoenix, AZ  85072-2066

Paper Claims Appeals fax: 1-855-230-5549

1. A member, a member’s representative, or the member’s provider must ask for an appeal. This request must include:

• • The member’s name and address
  • Their Neighborhood member ID number
  • The reason(s) for the appeal
  • All evidence that Neighborhood should review, such as medical records, doctors’ letters, or other information that explains why the item or service is needed. Members should contact their provider for all required information needed for the appeal that they do not already have.

2. Call, mail, fax, or hand deliver your appeal to Neighborhood.

For a Standard Appeal:

By phone: 1-844-812-6896 (TTY 711)

By mail: Neighborhood Health Plan of Rhode Island
Grievances and Appeals Department
910 Douglas Pike
Smithfield, RI 02917

By fax: 1-401-709-7005

If you ask for a standard appeal by phone, we will send you a letter confirming what you told us.

For a Fast Appeal:  

By phone: 1-844-812-6896 (TTY 711)

By fax:  1-401-709-7005

Members can ask to see the medical records and other documents Neighborhood used to make a decision before or during an appeal. They can also ask for a copy of the guidelines we used to make our decision. These documents and guidelines are free.

If an appeal for the authorization of a service request continues to be denied, Neighborhood will send a written decision to the member. This letter states if the service or item is usually covered by Medicare and/or Medicaid.

• If the service is covered by Medicare, Neighborhood will automatically send the case to an independent reviewer. If the independent reviewer denies the request, a letter will be sent to the member explaining additional appeal rights and outlining the process for next steps. Please note, this does not apply to Part D (prescription drug) appeals. For Part D (prescription drug) appeals, members or providers can request a reconsideration (second level appeal) with an independent reviewer by following the instructions on the appeal denial notice.
• If the service is covered by Medicaid, members can ask for a State Fair Hearing. Members may also ask for an External Review if the service being requested requires a medical necessity review. Both the State Fair Hearing and the External Review are conducted by independent entities that are not part of Neighborhood. The written decision provides members with instructions on how to request an external review and/or State Fair Hearing.

Visit eohhs.ri.gov/reference-center/eohhs-appeals-office for more information on State Fair Hearings.

If the service being appealed could be covered by both Medicare and Medicaid, Neighborhood will automatically send the appeal to the independent reviewer.

Members can receive an aggregate number of grievances, appeals and exceptions they have submitted. To receive this information, call Member Services at 1-844-812-6896 (TTY 711).

For more information about the appeals process, please refer to your Member Handbook or call Member Services at 1-844-812-6896 (TTY 711).

An authorized representative can help file a grievance (a complaint) or appeal on a member’s behalf. Members can name a relative, friend, advocate, provider, or anyone else as an appointed representative.

To legally appoint someone as a representative:

1. Download and complete a copy of the Centers for Medicare and Medicaid Services (CMS) Authorized Representative Form.
2. Mail or fax the signed form to Neighborhood:
   • By mail:
     Neighborhood Health Plan of Rhode Island
     Grievances and Appeals Department
     910 Douglas Pike
     Smithfield, RI 02917

• • By fax: 1-401-709-7005

If a member has a problem or concern, they can file a complaint directly with Medicare.

Members can file a complaint if they are having a problem with the quality of care they received or have a problem with Neighborhood. They can also file an appeal if they have an issue or got a bill for a claim they don’t think they should have gotten.

To file a complaint with CMS, visit https://www.medicare.gov/my/medicare-complaint.

• Part D Redetermination Request Form
  Use this form to file a Part D (Prescription Drug) appeal, also known as a redetermination request.

For help or additional information about Neighborhood’s decision and the appeal process, call Member Services at 1-844-812-6896 (TTY 711) 8:00 a.m. to 8:00 p.m., seven days a week from October 1 through March 31. From April 1 through September 30, you can call us 8:00 a.m. to 8:00 p.m. Monday through Friday. You may leave a voicemail on Saturdays, Sundays, and federal holidays. The call is free.

Members and authorized representatives may also contact:

• Medicare: 1-800-MEDICARE (1-800-633-4227) (TTY: 877-486-2048), 24 hours a day, 7 days a week
• Medicare Rights Center: 1-888-HMO-9050
• Elder Care Locator: 1-800-677-1116
• The POINT: 1-401-462-4444 (TTY 711)
• Legal Services (Rhode Island): 1-401-274-2652
• Rhode Island Insurance Resource, Education, and Assistance Consumer Helpline (RIREACH): 1-855-747-3224 (1-855-RIREACH); ripin.org; or email rireach@ripin.org

Neighborhood members can find complete information about Coverage Decisions, Appeals, and Grievances in Chapter 9 of the INTEGRITY for Duals Evidence of Coverage (Member Handbook) found on the Member Materials page of our website.