Grievances and Appeals

Grievances and Appeals

Your health and satisfaction are important to us. When you have a problem or concern, please call RiverSpring Star(HMO SNP) first at 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 SNP), please contact RiverSpring Star (HMO SNP) at 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 SNP) to change a coverage decision by filing an appeal. 

How to File an Appeal or Grievance

 If you need to Contact us to file an Appeal or Grievance, you can give us a call at 800-580-7000. If you’d like to write us regarding an Appeal or Grievance, write us at: RiverSpring Star, ATTN: Appeals & Grievance Dept. 94 W 225th St. 2nd Floor; Bronx, NY 10463. If you’d like to fax us your Grievance or Appeal, fax to: 1-888-810-0215.

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

If you’d like information on how to obtain an aggregate number of grievance, appeals, and exceptions filed with RiverSpring Star, contact the Appeals & Grievances Department at 1-800-580-7000—we’ll be happy to provide you with that information.

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

How to Request a Coverage Determination for medical care

How to request coverage for medical care?

When requesting coverage for medical care it is referred to 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 participant requests, or pay for a service a participant has received.

Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want at the contact information listed below. You, your doctor, or your representative can do this.

Call: 1-800-580-7000 8 a.m. – 8 p.m., 7 days a week TTY: 711 Fax: 1-866-889-3292 Or,

Write:

RiverSpring Health Plans
80 West 225 Street
Bronx, N.Y. 10463

 

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 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 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 October 15, 2018