Grievances (Parts C & D)

What is a complaint/grievance? 

A complaint/grievance is a formal way of telling us that you are unhappy about wait times at the doctor’s office, cleanliness of the doctor’s office, discourteous behavior by doctor’s office staff, or the quality of care received by a doctor. You can file a complaint/grievance to say you are unhappy with the timeliness, appropriateness, or access to any health service, procedure, or item as well. A complaint/grievance is also a formal way of telling us that you are unhappy about our decision on your request to expedite a decision or our refusal to provide certain services and our claims payment decisions. If you are dissatisfied with anything about us or our providers you may file a complaint/grievance. You need to file your complaint/grievance within 60 days of the occurrence. If you have a good reason for being late in filing a complaint/grievance, let us know and we will consider whether or not to extend the timeline for filing a complaint/grievance.

What do we do when you file a complaint/grievance? 

We will look into your complaint/grievance and, if possible, give you an answer right away. If you call us with a complaint/grievance, we might be able to give you an answer on that same phone call. Most complaints/grievances are answered no later than 30 calendar days from the date you file your complaint.

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint/grievance. However, if we take this extension, we will notify you or your representative. If your health condition requires us to answer quickly, we will do so.

Complaints made because we denied your request for a “fast coverage decision” or a “fast appeal” will automatically be considered a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

If we don’t agree with part or all of your complaint/grievance or don’t take responsibility for the problem you are filing, we will let you know and include reasons for this answer. We must respond whether we agree with your complaint/grievance or not.

For process or status questions, you or your provider can contact Member Services.

How to Obtain an Aggregate Number of Grievances, Appeals and Exceptions Filed with Wellcare By Health Net

To obtain an aggregate number of Wellcare By Health Net grievances, appeals and exceptions, please call Member Services.

For help with complaints, grievances, and information requests, you can contact The Office of the Medicare Ombudsman (OMO). 

To file a complaint directly with CMS – https://www.medicare.gov/MedicareComplaintForm/home.aspx.

Grievances (Parts C & D)

What is a complaint/grievance? 

A complaint/grievance is a formal way of telling us that you are unhappy about wait times at the doctor’s office, cleanliness of the doctor’s office, discourteous behavior by doctor’s office staff, or the quality of care received by a doctor. You can file a complaint/grievance to say you are unhappy with the timeliness, appropriateness, or access to any health service, procedure, or item as well. A complaint/grievance is also a formal way of telling us that you are unhappy about our decision on your request to expedite a decision or our refusal to provide certain services and our claims payment decisions. If you are dissatisfied with anything about us or our providers you may file a complaint/grievance. You need to file your complaint/grievance within 60 days of the occurrence. If you have a good reason for being late in filing a complaint/grievance, let us know and we will consider whether or not to extend the timeline for filing a complaint/grievance.

If you want someone else to file your complaint/grievance on your behalf:

Provide us with an Appointment of Representative Form or a legal document showing that you have chosen someone other than yourself to file for you and that this person has your permission to see all information including medical records about the complaint/grievance. More information and instructions for the Appointment of Representative Form are located on the Appeals and Grievances page.

What do we do when you file a complaint/grievance? 

We will look into your complaint/grievance and, if possible, give you an answer right away. If you call us with a complaint/grievance, we might be able to give you an answer on that same phone call. Most complaints/grievances are answered no later than 30 calendar days from the date you file your complaint.

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint/grievance. However, if we take this extension, we will notify you or your representative. If your health condition requires us to answer quickly, we will do so.

Complaints made because we denied your request for a “fast coverage decision” or a “fast appeal” will automatically be considered a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

If we don’t agree with part or all of your complaint/grievance or don’t take responsibility for the problem you are filing, we will let you know and include reasons for this answer. We must respond whether we agree with your complaint/grievance or not.

For process or status questions, you or your provider can contact Member Services.

How to Obtain an Aggregate Number of Grievances, Appeals and Exceptions Filed with Wellcare By Health Net

To obtain an aggregate number of Wellcare By Health Net grievances, appeals and exceptions, please call Member Services.

For help with complaints, grievances, and information requests, you can contact The Office of the Medicare Ombudsman (OMO). (By clicking on this link you will be leaving the Wellcare By Health Net website.)

To file a complaint directly with CMS – https://www.medicare.gov/MedicareComplaintForm/home.aspx (By clicking on this link you will be leaving the Wellcare By Health Net website.)

Grievances (Parts C & D)

What is a complaint/grievance? 

A complaint/grievance is a formal way of telling us that you are unhappy about wait times at the doctor’s office, cleanliness of the doctor’s office, discourteous behavior by doctor’s office staff, or the quality of care received by a doctor. You can file a complaint/grievance to say you are unhappy with the timeliness, appropriateness, or access to any health service, procedure, or item as well. A complaint/grievance is also a formal way of telling us that you are unhappy about our decision on your request to expedite a decision or our refusal to provide certain services and our claims payment decisions. If you are dissatisfied with anything about us or our providers you may file a complaint/grievance. You need to file your complaint/grievance within 60 days of the occurrence. If you have a good reason for being late in filing a complaint/grievance, let us know and we will consider whether or not to extend the timeline for filing a complaint/grievance.

If you want someone else to file your complaint/grievance on your behalf:

Provide us with an Appointment of Representative Form or a legal document showing that you have chosen someone other than yourself to file for you and that this person has your permission to see all information including medical records about the complaint/grievance. More information and instructions for the Appointment of Representative Form are located on the Appeals and Grievances page.

What do we do when you file a complaint/grievance? 

We will look into your complaint/grievance and, if possible, give you an answer right away. If you call us with a complaint/grievance, we might be able to give you an answer on that same phone call. Most complaints/grievances are answered no later than 30 calendar days from the date you file your complaint.

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint/grievance. However, if we take this extension, we will notify you or your representative. If your health condition requires us to answer quickly, we will do so.

Complaints made because we denied your request for a “fast coverage decision” or a “fast appeal” will automatically be considered a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

If we don’t agree with part or all of your complaint/grievance or don’t take responsibility for the problem you are filing, we will let you know and include reasons for this answer. We must respond whether we agree with your complaint/grievance or not.

For process or status questions, you or your provider can contact Member Services.

How to Obtain an Aggregate Number of Grievances, Appeals and Exceptions Filed with Wellcare By Health Net

To obtain an aggregate number of Wellcare By Health Net grievances, appeals and exceptions, please call Member Services.

For help with complaints, grievances, and information requests, you can contact The Office of the Medicare Ombudsman (OMO). 

To file a complaint directly with CMS – https://www.medicare.gov/MedicareComplaintForm/home.aspx.