Grievances & Appeals

File a Grievance

A “grievance” is a formal process for filing a complaint. If you are unhappy with your care or the service you’ve received, please let IIHCP know so we can try to resolve it for you first. You’ll find more information on the grievance process in your Evidence of Coverage, or call Member Services to file a grievance by phone.

Examples of Grievances:
– The quality of care you receive from your doctors
– Office waiting times
– The way you were treated by your doctor or office staff
– The condition of the medical offices
– The treatment you receive from IIHCP representatives
– Involuntary disenrollment issues
– Any other areas, except those related to coverage or payment (see below)

To file a grievance by mail:
Grievances & Appeals Resolution Services
Attention: IIH Community Plans
PO Box 592
Fresno, CA 93709

Please note: If your complaint is about a decision related to coverage of care or payment of services, the grievance process does not apply. Instead, you can file an appeal.

Call Member Services, we’re happy to help:
1-888-900-6807, TTY: 711
Hours are 8 a.m. to 8 p.m., seven days a week from October 1st to March 31st, and 8 a.m. to 8 p.m. Monday through Friday from April 1st to September 30th.

File an Appeal

An appeal is a formal process that deals with the review of adverse organization determinations on the health care services a member believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services.

Medicare Part C Benefits: Filing an Appeal

If you have problems getting coverage for medical care or if you want us to pay you back for our share of the cost of your care you can file an appeal. If we say no to your request for coverage for medical care, we have a formal procedure to review your denial. We call this the appeal process.

As an IIHCP member you may file the appeal yourself or appoint someone to do it for you. This person you appoint would be your authorized representative. You can appoint a relative, friend, advocate, doctor, attorney, or other person to act for you. If you already have someone authorized under state law to act for you, this person can file the appeal on your behalf. You can download the CMS Appointment of Representation form (Form CMS-1696) from the CMS website.

To start an appeal you, your doctor, or your representative, must contact us. If your health requires a quick response, you must ask for a “fast appeal.”

If you are asking for a standard appeal, you must make your appeal in writing by submitting a signed request.

If you are asking for a “fast appeal”, you may make your appeal in writing or by calling our Member Services Department at the number listed above. To make a written appeal, you may send your request via FAX to: 1-855-400-5543 or by mail to:

Grievances & Appeals Resolution Services
Attention: IIH Community Plans
PO Box 592
Fresno, CA 93709

You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

We must address your appeal as quickly as your case requires based on your health status, but no later than 30 days after receiving your request. When you request a “fast appeal”, we must give you our answer within 72 hours, only if meets the Medicare criteria for a “fast appeal”. We may extend the time frame for an appeal 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. If we deny your appeal in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.

Should you have appeal process or status questions, please contact our Member Services Department at the number listed above.

For more detailed information on the appeal process please refer to your Evidence of Coverage.

IIHCP is committed to maintaining high levels of member satisfaction. We continuously strive to improve our services through member feedback so please reach out for assistance.

Medicare Part D Prescription Benefits: File a Redetermination/Appeal

An appeal to the plan about a Part D Drug Coverage Decision we made is called a Redetermination (Appeal). Use this process to ask us to review a Part D drug Coverage Decision made by us. You cannot request a Part D Redetermination (Appeal) if we have not issued a Coverage Determination.

To start your Part D Redetermination (Appeal), you (or your representative or your doctor or other prescriber) must contact us. For a standard appeal:

Fax request to: 1-855-400-5543

Mail request to:
Grievances & Appeals Resolution Services
Attention: IIH Community Plans
PO Box 1123
Eau Claire, WI 54702

If you are asking for a fast appeal, write to us at the address above or call our Member Services Department.

Your written request should include the following information: 

– Member Name
– Member ID number – found on your IIHCP membership card
– Name of the Part D drug that you are asking us to review
– Reason you do not agree with the initial Coverage Determination
– Date of initial Coverage Determination notice

Or simply download, fill out and submit the following form: IIHCP Redetermination Request Form

For more detailed information on the appeal process please refer to your Evidence of Coverage or contact us or call Member Services at 1-888-900-6807 for additional information. (TTY Users: 711). Hours are 8 a.m. to 8 p.m., seven days a week from October 1 to March 31, and 8 a.m. to 8 p.m. Monday through Friday from April 1 to September 30.

Appoint a Representative
Category: File an Appeal

If you decide to ask for a coverage decision or appeal a decision, either about your medical coverage (Part C) or your drug coverage (Part D), you can submit the request yourself or you can name another person to act for you as your “representative.”

There may be someone who is already legally authorized to act as your representative under State Law. If so, send us a copy of the form that names the person that can act on your behalf.

If you don’t have someone to act on your behalf you can choose a friend, relative, your doctor or other provider or other person to be your representative and complete an Appointment of Representative form. The form must be signed by you and by the person who you would like to act on your behalf.

Complete the form making sure that both you and your representative sign the form. Print a copy for your records. Send a copy to the same location where you are sending (or have already sent) your appeal if you are filing an appeal, grievance if you are filing a grievance, initial determination or decision if you are requesting an initial determination or decision.

You may obtain a copy of the Appointment of Representative form by clicking on the links below:

Appointment of Representative
Nombramiento de un Representante

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