Medicare Part C Grievances, Coverage Decisions and Appeals Summary

The resource information linked to the Advantage Medicare Plan formulary web page pertaining to grievances, coverage decisions (including exceptions), and appeals processes are taken directly from the Evidence of Coverage (EOC) document Members receive at the beginning of each year. To print a copy of the current plan year Evidence of Coverage (EOC) for ADVANTAGE Choice, please click the link.

Click on a topic below for more information.


Topic
Details
Instructions for
Filing a Grievance or Complaint

Located in Chapter 7, Section 9 of the EOC: Making Complaints

To submit a grievance verbally, contact Customer Service at:
918-594-5202 or 1-800-333-3275, TTY/TDD: 1-800-722-0353, Monday – Friday 8:00 a.m. to 8:00 p.m. central time.

To submit a formal grievance in writing, send to:

Advantage Medicare Plan
Attn: Grievance and Appeals Department
P.O. Box 340, Tulsa, OK 74101-0340

Fax Number: 918-879-4048

In person: 4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center)

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Part C Coverage Decision Requests about Medical Care

Located in Chapter 7, Section 5 of the EOC: How to ask for a Coverage Decision or Make an Appeal.

To request a coverage decision verbally, contact Customer Service at 1-800-333-3275 or 1-918-594-5202 (local), TTY/TDD: 1-800-722-0353, Monday – Friday 8:00 a.m. to 8:00 p.m. central time.


To submit a request in writing, send to:

Advantage Medicare Plan
Attn: Customer Service
P.O. Box 340, Tulsa, OK 74101-0340

Fax Number: 918-594-5250

In person: 4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center)

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Making an Appeal about Part C Medical Care

Located in Chapter 7, Section 5 of the EOC: How to ask for a Coverage Decision or make an Appeal

If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. A standardized appeal request form is available. However, you may submit your request in any format. To print this form, click on the following link:

To submit an appeal request in writing, sent to:

Advantage Medicare Plan
Attn: Grievance and Appeals Department
P.O. Box 340, Tulsa, OK 74101-0340


Requests for appeals must be in writing unless the request is for a fast or expedited decision. Members must file their appeal request within 60 calendar days from the date included on the notice of the coverage decision. Exceptions may be granted if you have a good reason for missing the deadline.

To submit a fast appeal verbally, contact Customer Service at 1-800-333-3275 or 918-594-5202 (local); TTY/TDD: 1-800-722-0353. Monday – Friday 8:00 am to 8:00 pm central time.

Fax Number: 918-879-4048

In Person: 4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center)


When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we complete the appeal review, we will give you our decision in writing.

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Questions about Grievances, Coverage Decisions and Appeals

Specific questions about grievances, coverage decisions and appeals can be answered by our Customer Service Department.

Contact Customer Service at: 918-594-5202 or 1-800-333-3275, TTY/TDD: 1-800-722-0353, Monday – Friday 8:00 a.m. to 8:00 p.m. central time.

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Appointment of Representation

Located in Chapter 7 of the EOC: What to do if you have a problem or complaint


If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. A standardized form is required to be completed to appoint a representative. To print this form, click on the following link:

This form is also available on Medicare's website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf.


Instructions for completing the Appointment of Representative form:

Section 1: The member (beneficiary) completes the requested information in Section I including the name of the individual they appoint as their representative. The beneficiary’s signature is required.
Section 2: This section is completed by the individual the beneficiary has named as their representative. The representative’s signature is required.
Section 3 and Section 4: These sections may not apply. See page 2 of the form for further information.

To submit a completed Appointment of Representation Form, send to:

Advantage Medicare Plan
Attn: Grievance and Appeals Department
P.O. Box 340, Tulsa, OK 74101-0340

Fax Number: 918-879-4048

In person: 4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center)

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Obtaining an aggregate number of grievances and appeals

For information on how to obtain an aggregate number of grievances and appeals, contact Customer Service at: 918-594-5202 or 1-800-333-3275, TTY/TDD: 1-800-722-0353, Monday – Friday 8:00 a.m. to 8:00 p.m. central time.

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Additional References in Chapter 7 of the EOC

For additional detail on coverage decision and appeals, the following sections in Chapter 7 are located in your 2019 Evidence of Coverage for ADVANTAGE Choice:

  • Section 4 - A guide to the basics of coverage decisions and appeals.
  • Section 5 - Your medical care: How to ask for a coverage decision or make an appeal.
  • Section 6 - How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon.
  • Section 7 - How to ask us to keep covering certain medical services if you think your coverage is ending too soon.
  • Section 8 - Taking your appeal to Level 3 and beyond.
  • Section 9 - How to make a complaint about quality of care, waiting times, customer service, or other concerns.
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