How to File a Grievance or an Appeal
We hope you will always be happy about the benefits and care you receive. If you are not, we want you to let us know right way. There are 2 ways you can express your concerns: You can file an appeal or a grievance.
You will not lose your Passport membership, benefits or have anything negative happen if you file an appeal or a grievance.
1. Filing an Appeal
As a Passport member, you have the right to file an appeal about any adverse benefit determination (ABD) we take. An example of an ABD is when we:
- Deny or limit approval of a service you or your doctor requested. This denial could be based on medical necessity rules, the appropriateness, setting or effectiveness of a covered benefit.
- Reduce or stop a medical service we approved.
- Do not agree to pay for a medical service.
- Do not provide services in a timely manner.
- Deny your request to get medical services from providers who are not signed up (in-network) with Passport.
- Limit the number of providers or pharmacies you can use.
- Deny your request if you disagree with the amount of money you have to pay. This might include cost sharing, copays, premiums, deductibles or coinsurance.
How to File an Appeal with Passport
- You have 60 days to file an appeal from the date of the notice you receive telling you about the ABD.
- You may call us to appeal, but you must follow-up with a written appeal request within 10 days of the call. Send your written appeal to:
Appeals Coordinator, Passport Health Plan
5100 Commerce Crossings Drive
Louisville, KY 40229
- If you need help with your appeal, please call Member Services at 1-800-578-0603. If you are a TDD/TTY user, please call 1-800-691-5566.
Naming Someone to Represent You
You can name someone else to appeal for you. For example, you may allow your doctor to file your appeal. If you name someone, you must first sign a letter saying:
- It is okay for him or her to represent you.
- The specific ABD you are appealing.
- The date you signed the letter.
You must give Passport a copy of this signed letter along with your appeal.
What happens after you file an appeal?
- When you file an appeal, we will send you a letter within 5 working days. The letter will tell you that we have received your appeal. It will also tell you the date and time we will review your appeal.
- After you have filed your appeal, you can still send us anything related to your appeal. We will use this information as long as we receive it by your appeal review date. You can also present it in person on the appeal date stated in our letter.
- If at any time during the appeal process, you need more time to give us things related to your appeal, you may request up to 14 more days. You must send this request in writing to the Passport Appeals Coordinator.
- If we feel we cannot give you a decision within the required 30 calendar days, we may add up to 14 calendar days to our review time. We will send you a letter within 2 working days to let you know this.
- If you are getting approved services that are now denied and you want to keep getting these services, you must ask for an appeal in writing. Your request must clearly state that you wish to keep getting the services. You can keep getting services until the appeal or State Hearing decision is made. If the appeal or State Hearing decision agrees with Passport’s denial, you may have to pay for the services.
- We will make an appeal decision within 30 calendar days of receipt. We will send you a letter with our decision.
- You may get free copies of any documents related to your appeal or copies of any information we used to decide medical necessity. You must ask for them in writing.
If your appeal involves a medical issue, a doctor with the same medical skill as your PCP or specialist, will handle your appeal. This doctor will not be the same doctor who denied the service.
Expedited (Fast) Medical Appeals
You can request an expedited (fast) appeal if your appeal is about care that you believe is medically necessary and needed soon. You will get an expedited appeal if waiting for a regular appeal could badly harm your health or life. If your request does not qualify for an expedited appeal, it will become a regular appeal.
You can make your request by calling 1-800-578-0603, press 0, then press 7307. If your request qualifies as an expedited appeal, we will let you know a decision within 3 working days. If you want to give us more information about your expedited appeal, please call us at 1-800-578-0603, press 0, then press 7307. You must do so right away as we will need to make a decision in 3 working days.
Your Right to Request a State Hearing
If you are not happy with Passport’s appeal decision, you may ask for a State Hearing with the Department for Medicaid Services (DMS). You must send your request for a State Hearing to DMS within 120 days of Passport’s final appeal decision. A State Hearing is not a part of Passport in any way. You must complete Passport’s appeal process before requesting a State Hearing.
To request a State Hearing with DMS, send your request in writing, by fax or in person to:
Kentucky Department for Medicaid Services
Division of Program Quality & Outcomes
275 East Main Street, 6C-C
Frankfort, Kentucky 40621
If you have any questions about a State Hearing with DMS, please call 1-800-635-2570. If you are hearing impaired, please call the Kentucky Relay by dialing 711.
You may also contact Kentucky’s Ombudsman if you have a complaint about your local Department for Community Based Services office:
Office of the Ombudsman Cabinet for Health Services
275 East Main Street, 1E-B
Frankfort, KY 40621
If you are a TDD/ TTY user, please call 1-800-627-4702.
You may call Member Services at 1-800-578-0603 anytime you have a question. You do not have to file an appeal or grievance to speak with us about an issue.
2. Filing a Grievance
You can file a grievance about anything other than an action. Remember, you may file an appeal from any action. Please see the list of actions under the appeals section.
How to File a Grievance
You can file a grievance about anything other than an adverse benefit determination (ABD). Please see the list of ABD’s under the “Filing An Appeal”section.
You may file a grievance orally or in writing. To tell us your grievance, please call Member Services at 1-800-578-0603. You may call from 7 am to 7 pm EST Monday through Friday. We can help you file your grievance and answer any questions you have. If you wish to mail your grievance, please mail to:
Passport Health Plan
5100 Commerce Crossing Drive
Louisville, KY 40229
If you do not speak English and need a translator to help file your grievance, please call Member Services at 1-800-578-0603 and let us know.
What happens after you file a grievance?
- After you file a grievance, we will send you a letter within 5 business days. The letter will tell you we received your grievance and give you our expected resolution date.
- The grievance review will be handled by someone who was not involved in the initial decision.
- Your grievance will be resolved within 30 calendar days of our receipt. We will send you a letter with our findings. If you or Passport needs extra time, we may add up to 14 calendar days.
If a person or organization has a complaint or grievance regarding the marketing practices of Passport, the person or organization should submit the information to the Passport Marketing Controller (see address below). The written information should include a description of the suggestion or the facts of the issue. The Marketing Controller will acknowledge the suggestion, complaint or grievance within ten (10) calendar days of receipt. Passport will review the suggestion, complaint or grievance and notify you of its comment or determination in writing within thirty (30) calendar days of receipt.
Attn. Marketing Controller
Passport Health Plan
5100 Commerce Crossings Drive
Louisville, Kentucky 40299