Medical Coverage Determination, Appeals, and Grievances
As a member of Johns Hopkins Advantage MD, you have a right to request an organization determination. (To keep things simple, we use “coverage decision” rather than “organization determination.”) If the plan denies coverage for your requested item or service, you have the right to appeal and ask us to reconsider the decision. You also have a right to file a grievance (also called a complaint) about the health plan.
Where do get more information about Advantage MD's appeals, grievance, and coverage decision process?
What is a coverage decision?
How do I request a coverge decision?
How do I request an expedited or fast coverage decision?
What is an appeal?
How do I make an appeal?
What happens when I make an appeal?
What are the deadlines for a ``standard`` appeal?
What are the deadlines for a ``fast`` appeal?
What is a grievance?
Who may file a grievance?
How do I file a grievance?
What is an expedited (fast) grievance?
What is a grievance resolution?
What is a quality of care complaint?
Appointing a Representative
You may name someone to act for you as a representative for filing an appeal or grievance. This person can be a relative, friend, lawyer, advocate, doctor or someone else. You may already have someone authorized by the Court or in accordance with State law to act for you. To authorize someone to act as your representative, you and that person must sign and date a statement that gives the person legal permission to do so. You may access the Appointment of Representative form.
Print, sign, and mail the form to:
Johns Hopkins Advantage MD
P.O. Box 3538
Scranton, PA 18505
Or fax to: 1-855-206-9206
File a Complaint with Medicare
You can also submit a complaint about your Medicare health plan or prescription drug plan directly to Medicare using the link to the Medicare Complaint Form.
The Office of the Medicare Ombudsman can also help you with complaints and grievances. To access the Office of the Medicare, please use the following link: Office of Medicare Ombudsman.
Rights and Responsibilities Upon Disenrollment
Ending your membership in Johns Hopkins Advantage MD may be voluntary (your own choice) or involuntary (not your own choice):
If you are voluntarily ending your membership, there are only certain times during the year, or certain situations, when you may do so. See your Evidence of Coverage for more specific information on how to end your membership.
There are some situations where you would be required to leave the plan, if you move out of the Johns Hopkins Advantage MD service area or if Johns Hopkins Advantage MD leaves the Medicare program.
If you are leaving our plan, you must continue to get your medical care and prescription drugs through our plan until your membership ends.