Coverage Requests, Appeals, and Complaints

If you have a request for coverage or complaint of any kind, we want to know about it so we can help to resolve your concerns.  There are different types of coverage requests and complaints.  We have provided you with a quick list for your reference and contact information to help you get started.

At FirstCare Advantage Dual SNP (HMO SNP), we understand that navigating through complicated rules can be frustrating.  So any time you have a question, we want you to give us a call. Our Customer Experience Ceneter Representatives are trained to help you with all your health plan needs.

Coverage Requests, Appeals, and Complaint

Organization Determinations – You can request FirstCare Advantage Dual SNP (HMO SNP)to make a decision on any type of service or a payment for medical care, such as surgery.  This can be completed by you as a member or by the provider.  FirstCare Advantage Dual SNP (HMO SNP)can deny or approve the service.  If we deny the service, there are appeals rights available to you.

How do I ask for an Organization Determination?

Call:
1-800-884-4905 (Prior Authorization) or 1-866-229-4969 (Customer Experience Center)
  • October 1- March 31, from 8 a.m.-8 p.m. Central Time (CT) Daily
  • April 1 – Sept. 30, from 8 a.m.-8 p.m. Central Time (CT) Monday through Friday. 
Write
FirstCare Advantage Dual SNP (HMO SNP)
Attention: Complaints & Appeals Department
12940 N. Hwy 183
Austin, TX 78750
Fax: 1-806-784-4190
Toll Free Fax: 1-877-878-8422

What if my coverage or payment is denied?

Appeals – if we deny coverage or payment for an item, medical service or a prescription that you think we should cover or pay for, you may request an appeal.  You can ask us to “expedite” or give you a quick decision if we have denied coverage (but not if your appeal is related to payment for services you already received).

How do I ask for an appeal for medical care?

Call:
1-866-229-4969 (Customer Service)
  • October 1- March 31, from 8 a.m.-8 p.m. Central Time (CT) Daily
  • April 1 – Sept. 30, from 8 a.m.-8 p.m. Central Time (CT) Monday through Friday. 
Write
FirstCare Advantage Dual SNP (HMO SNP)
Attention: Complaints & Appeals Department
12940 N. Hwy 183
Austin, TX 78750
Fax: 1-806-784-4190
Toll Free Fax: 1-877-878-8422

What if I was discharged from an inpatient hospital too soon?

Inpatient Hospital Discharge– if you think you are being discharged from the hospital too soon, you may request that the QIO (Quality Improvement Organization) review your discharge from the hospital.

How do I contact the QIO?

KePRO
Call: 1-844-430-9504
TTY: 1-855-843-4776
Fax: 1-844-834-7129

Write:
KePRO
Rock Run Center
5700 Lombardo Center, Suite 100
Seven Hills, OH 44131
Website:
 www.keproqio.com

Fast Track appeal for Home Health, Skilled Nursing Facility or Comprehensive Outpatient Rehabilitation Facility – If you are receiving approved services from a Home Health, Skilled Nursing Facility or Comprehensive Outpatient Rehabilitation Facility, and you think that your covered services are ending too soon, you may ask for a “Fast Track” appeal to an independent entity called “Quality Improvement Organization", or QIO. The QIO for FirstCare Advantage Dual SNP is KePRO. Your provider will issue you a “Notice of Medicare Non – Coverage” at least forty-eight (48) hours prior to the last day of coverage. This Notice provides valuable information on your appeals rights. Please review your Notice of Medicare Non- Coverage carefully to understand your rights for appeals and the timing you must follow to make an appeal either to the QIO or to FirstCare Advantage Dual SNP.

How do I ask for an expedited appeal?

Expedited Appeals- You can request an expedited (fast) appeal if you or your doctor believes that waiting for a decision under the standard time frame could place your life, health, or ability to regain maximum function in serious jeopardy. For an expedited appeal, you should contact us by telephone or fax at the numbers below:
 
FirstCare Advantage Dual SNP (HMO SNP)

Call
1-866-229-4969 (Customer Service)
  • Oct. 1 -  March 31, from 8 a.m. - 8 p.m. Central Time (CT) Daily
  • April 1 - Sept. 30, from 8 a.m. - 8 p.m. Central Time (CT) Monday through Friday. 

Write:
FirstCare Advantage Dual SNP
Attention: Complaints & Appeals Department
12940 N. Hwy 183
Austin, TX 78750
Fax: 1-806-784-4190
Toll Free Fax: 1-877-878-8422

Asking for Prescription Drugs to be Covered

Coverage Determinations – You or your physician requests a drug from FirstCare Advantage Dual SNP (HMO SNP), such as a drug that is not on the formulary. FirstCare Advantage Dual SNP (HMO SNP)works with its Pharmacy Benefits Manager, Express Scripts to review Coverage Determinations.  Your request will reviewed and a coverage decision will be provided to you and your physician.  You may ask for an expedited coverage decision if you feel you need a fast decision.

FirstCare Health Plans

ATTN: Pharmacy Department – Medicare Part D Coverage Decisions
12940 N. Hwy 183
Austin, TX 78750

For more information and the Part D Coverage Determination form or to access the form, please use the following link:

https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/Downloads/ModCovDetReqForm-and-InstrctnsOct-2011-508-.zip
Appeals – if we deny coverage or payment for a prescription that you think we should cover or pay for, you may request an appeal.  You can ask us to “expedite” or give you a quick decision if we have denied coverage (but not if your appeal is related to payment for services you already received).

How do I ask for an appeal for prescription drug coverage?

FirstCare Health Plans
Attention: Complaints & Appeals Department
12940 N. Hwy 183
Austin, TX 78750

Filing a Complaint

Complaints– If you have a complaint related to the quality of the care you receive, the timeliness of services or any other concern, you may file a complaint. You can call us to file an informal (verbal) complaint.  To file a formal (written) complaint write us a letter, or call Customer Service and they will mail you a form.  Either way, we’ll get to work to solve your problem right away.  You also have the right to file a grievance with the QIO if it is related to the quality of care you have received or timeliness of services.

How do I file a complaint?

Call:  1-866-229-4969 (Customer Experience Center)
  • Oct. 1 -  March 31, from 8 a.m. - 8 p.m. Central Time (CT) Daily
  • April 1 - Sept. 30, from 8 a.m. - 8 p.m. Central Time (CT) Monday through Friday. 
Write
FirstCare Advantage Dual SNP (HMO SNP)
Attention: Complaints & Appeals Department
12940 N. Hwy 183
Austin, TX 78750
Fax: 1-806-784-4190
Toll Free Fax: 1-877-878-8422


KePRO Quality Improvement Organization (QIO)
Call: 1-844-430-9504
TTY: 1-855-843-4776
Fax: 1-844-834-7129

Write
KePRO
Rock Run Center
5700 Lombardo Center, Suite 100
Seven Hills, Ohio 44131 Website:
 www.keproqio.com/
 
Medicare.gov
Call: 1-800-Medicare
Complaint Web Link:
 https://www.medicare.gov/MedicareComplaintForm/home.aspx?AspxAutoDetectCookieSupport=1
 
Office of the Ombudsman

Call: 1-877-787-8999

Write:
Texas Health and Human Services Commission of the Ombudsman
PO Box 13247
Austin, Texas 78711-3247

Get More Information

A complete description of the Complaints process is available in your Evidence of Coverage. Below are helpful links to the Complaints and Appeals Processes in your Evidence of Coverage.

Appointing Another Party to File a Complaint or Appeal on Your Behalf

Appointment of Representative - If you desire someone to be your representative for an Appeal or Grievance, you can appoint that person to represent you on your behalf.

How do I appoint a representative?

For more information go to:
http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf

Remember, you can give us a call whenever you have a question or need assistance.
We’re here to help!
 

Resources

Virtual Care Powered by MDLive

We've teamed up with MDLIVE to provide our members with access to Telehealth visits to board-certified doctors, pediatricians, licensed therapists and more- using your smartphone, tablet or desktop.  ***Available January 1, 2019***

Talk to a Nurse—Nurse24™

Need care advice? Should you see a doctor? Get the info you need today! FirstCare members can talk to a nurse 24/7 by calling 1.855.828.1013 to get answers 24 hours a day, 7 days a week! TTY users can call 7-1-1 or  1.800.955.8771. Voice communication is available at 1.800.955.8770.

Utilization Management

Ever wonder how we decide what services to authorize? Our utilization management (UM) decisions are based on medical evidence and consensus of health care professionals. For more details, click here.

How to Learn More

Schedule a sit-down:
Feel free to contact us, and a FirstCare Advantage Dual SNP (HMO SNP) representative will gladly sit down with you and compare the plans in greater detail.
 
Call us at:
1- 866- 229-4969
We are available;
October 1- March 31, 8 a.m. to 8 p.m. Central Time (CT) daily;
April 1- September 30, 8 a.m. to 8 p.m. Central Time (CT) Monday through Friday.
 
For TTY or for accommodation of persons with special needs, please call TTY 1-800-562-5259.
 
Or, write:
FirstCare Advantage Dual SNP (HMO SNP)
Attn:  Customer Service
1901 West Loop 289, Suite 9
Lubbock, TX 79407

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