700 Main Street, Suite 100
Alamosa, CO 81101
Hours: 8:00 am-8:00 pm
7 days a week
EXCEPTIONS, GRIEVANCES AND APPEALS
The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for medical services and prescription drugs, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered.
Asking for coverage decisions
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for medical services. We and/or your doctor make a coverage decision for you whenever you go to a doctor for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.
We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
Making 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. When you make an appeal we review the coverage decision we have made to check to see if we were following all the rules properly. When we have completed the review we give our decision. If we say not to all of part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal.
Would you like someone to help? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:
You can call us at Customer Services-800-475-8466
To get free help from an independent organization that is not connected with our plan, contact you State Health Insurance Assistance Program-1-888-696-7213
Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision or a Level 1 Appeal on your behalf. To request any appeal after Level 1, your doctor or other provider must be appointed as your representative.
You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal.
There may be someone who is already legally authorized to act as your representative under State Law.
If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Customer Service and ask for the form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.
You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision.
For written requests you can fax or send the information.
Address: 700 Main Street, Suite 100
Alamosa, CO 81101
For oral requests please call 719-589-3696 or 800-475-8466.
This information is also contained in Chapter 7 of the Evidence of Coverage document.
A Health Plan with a Medicare contract.
DISCLAIMER We renew our contract with Medicare annually. The availability of coverage beyond the end of the current year is not guaranteed.
Benefits, premium and/or copayments/coinsurance may change each year on January 1. Benefits may be subject to copayments, limitations and/or restrictions. See the Evidence of Coverage or contact Customer Service for details.
The benefit information contained herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan.
You are eligible to enroll if you are entitled to Medicare Part A and enrolled in Medicare Part B and you live in the service area. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. Eligible beneficiaries can enroll in Colorado Choice at any time.
You can use any doctor who is part of Colorado Choice's network. You may also go to doctors outside of our network. We may not pay for services you receive outside of our network, but Medicare will pay for its share of charges it approves. You will be responsible for paying the Medicare deductible and coinsurance for those services, unless they were authorized in advance by Colorado Choice.
Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits.
Information is available in alternative formats or languages. Please call 1-800-475-8466 for details. Se puede presentar la información acerca del plan en un formato o idioma distinto. Para solicitar un documento en español, favor de llamar a Atención al Cliente, al número telefónico indicado debajo.
For more information, contact Customer Service at 1-800-475-8466 toll free or 719-589-3696, 8:00 a.m. to 8:00 p.m., 7 days a week. If you are hearing impaired and use TTY equipment, call 1-800-659-2656 (Para asistencia en español llame al 1-800-475-8466.
Information is current as of 11/27/2011. Please contact our Customer Services department to verify that you have the most up to date information.