Grievances and Appeals

Your health and satisfaction are important to us. When you have a problem or concern, please call RiverSpring Star(HMO I-SNP) first at 1-800-580-7000. Our members service staff will work with you to try to find a satisfactory solution to your problem.

You can also contact us to ask about the grievance and appeals process, or a status update on the processing of your grievance or appeal. For information on the total number of grievances, appeals and exceptions filed with RiverSpring Star (HMO I-SNP), please contact RiverSpring Star (HMO I-SNP) at 1-800-580-7000.

For more information, please see Chapter 9 of the Evidence of Coverage

Grievances

A grievance is a complaint that you have a problem or concern about your covered services or care. This includes any concerns about the quality of your care, our network providers, or our network pharmacies.

Appeals

An appeal is a way for you to challenge a coverage decision if you think it is wrong. You can ask RiverSpring Star (HMO I-SNP) to change a coverage decision by filing an appeal.

How to Request a Coverage Decision or File an Appeal or Grievance

When requesting coverage for medical care, it is called a request for an organization determination. An organization determination, also known as a service authorization, is the plans initial decision about whether we will provide the medical care or service a member requests, or pay for a service a member has received.

To request a coverage decision or file an appeal or complaint about your medical care, you may call or write to us at:

RiverSpring Star (I-SNP)
Attn: Appeals & Grievances
80 West 225th Street
Bronx, New York 10463

Phone: 1-800-580-7000 (TTY/TDD: 711), 7 days a week, 8 a.m. to 8 p.m. ET.

Fax: 1-888-341-5009

If you need to file a grievance  directly with Medicare, please fill out the Medicare Complaint Form.

To request a coverage decision or file an appeal or complaint about Part D Prescription Drugs, you may call or write to us at:

MeridianRx
1 Campus Martius, Suite 750
Detroit, MI 48226

Phone: 1-855-898-1482 (TTY/TDD: 711), 24 hours a day, 7 days a week.

Fax: 1-855-898-1483

For coverage determination, grievance and appeals process, please review Chapter 9 of your Evidence of Coverage. Chapter 9 explains the process that is available for you to choose from when you either have a problem with coverage of medical services or prescription drugs. If you would like help with a coverage determination, grievance or appeal process, contact Member Services at 1-800-580-7000 (TTY/TDD: 711), 7 days a week, 8 a.m. to 8 p.m. ET.

Appointment of Representative

If you need help with a grievance, coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.”

The Appointment of Representative form must be signed by you and by the person whom you would like to act on your behalf.

You or your appointed representative can file a grievance or appeal by calling or writing to us.

Please follow the link for the
Notice of Nondiscrimination and Accessibility Requirements

Timeframes For Filing An Organization Determination:

Expedited Organization Determination: Notification of a decision will be given as quickly as the participant’s health condition requires but no later than 72 hours of receiving the request. RiverSpring Health Plans may extend the timeframe by up to 14 calendar days if the member requests the extension or if we need additional information and the extension of the time benefits you.

Standard Organization Determination: Notification of a decision will be given as quickly as the participant’s health condition requires but no later than 14 calendar days of receiving the request. RiverSpring Health Plans may extend the timeframe by up to 14 calendar days if the participant requests an extension or RiverSpring may grant itself an extension if it is in the best interest of the participant.

Claim Organization Determinations: Notification of a decision will be made within 30 calendar days for claims from non-contracted providers and all other claims within 60 calendar days.

Last updated on February 14, 2020