For Members

Coverage Decisions, Appeals & Grievances

Coverage Decisions

A coverage decision is a decision we make about your medical care or prescription drug benefits and coverage or about the amount we will pay for your medical care services or prescription drugs.

Appeals

An appeal is a formal way of asking us to review and change a coverage decision we have made.

Grievances

A grievance is a complaint about Aspire, a network provider, or a pharmacy, including concerns about the quality of care or service you received. Grievances do not involve coverage decisions or appeals.

Detailed information about Coverage Decisions, Appeals and Grievances can be found in the Evidence of Coverage.

View Evidence of Coverage

Filing a Grievance

You must file a grievance within 65 calendar days of the issue or event you wish to complain about.

Grievance Review Timeframes

The time it takes to review and resolve your grievance depends on the type of grievance filed:

Standard Grievance

We will review your grievance and make a decision as quickly as your health condition requires, but no later than 30 calendar days after we receive your request. We may extend this timeframe by up to 14 calendar days if doing so is in your best interest. You will receive a written notice informing you of the decision or any extension.

Expedited “Fast” Grievance

If your grievance is about our decision not to grant a fast coverage determination or a fast appeal, it will automatically be handled as an expedited grievance. A decision will be made within 24 hours of receiving the grievance. We may extend this timeframe by up to 14 calendar days if doing so is in your best interest. You will first be notified by telephone, followed by a written notice of the decision or any extension.

To file a Grievance or to check on the status of an in-process grievance, you may contact us:

Call
Toll-free (855) 570-1600 (TTY 711)
Local: (831) 574-4938 (TTY 711)
Calls to these numbers are free.

Hours of operation are:
8 a.m. to 8 p.m., 7 days a week

MEDICARE: You can submit a complaint directly to Medicare or call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.

You can also use some of Medicare’s standard forms in lieu of forms we have provided on this website.

Fax
Local : (831) 920-5903
Toll-free (855) 519-5769

Write
Aspire Health Plan Attn:
Appeals and Grievance Department
10 Ragsdale Dr, Suite 101
Monterey, CA 93940

Forms
Appeal and Grievance Form (PDF): English | Español

You are entitled to obtain an aggregate number of grievances, appeals, and exceptions filed with Aspire Health Plan. You may do so by calling our Member Services number at 855-570-1600. Hours are 8 a.m. to 8 p.m. PT M – F from 4/1 – 9/30, 8 a.m. – 8 p.m. PT 7 days a week from 10/1 – 3/31 (except certain holidays).

Appointing a Representative (AOR)

You have the right to appoint someone to act on your behalf when requesting a coverage decision, filing an appeal, or submitting a grievance. To do so, you must complete an Appointment of Representative Form (PDF).
The form must be signed by both you and the person you are appointing as your representative. Once completed, submit the form by fax or mail using the applicable fax number or mailing address listed above. We must receive and process the form before we can discuss your case with your representative.

Please note

This form authorizes your representative to assist you with coverage requests, grievances, and appeals.
Your doctor may request coverage determinations and file certain appeals on your behalf without being designated as your representative.
•The Appointment of Representative Form is valid for one year from the date it is signed.
You may revoke this authorization at any time by notifying us.

Appointment of Representative Information Form (PDF): English | Español

Part C Medical Appeals

A Medical Care (Part C) Appeal must be requested within 65 calendar days from the date on the Medical Care Coverage Decision notice. If you have a good reason for missing this deadline, we may give you more time. Examples of good cause may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.

There are two different types of Medical Care (Part C) Appeals.

Claim payment Medical Care (Part C) Appeal – an appeal made for payment when a Medical Care Coverage Decision has been made to fully or partially deny a medical care claim.
Pre-Service Medical Care (Part C) Appeal – an appeal made for coverage when a Medical Care Coverage Decision has been made to fully or partially deny coverage for a medical care procedure or treatment.

There are different time frames for Medical Care (Part C) Appeals reviews and decisions:

Standard claim payment Medical Care (Part C) Appeal: A decision must be made no later than 60 calendar days after receiving the request. You will receive a letter informing you of the results of the review.
Standard pre-service Medical Care (Part C) Appeal: A decision must be made as quickly as your health requires, but no later than 30 calendar days after receiving the request. You and your provider will receive a letter about the results of the review. Aspire Health Plan can extend the decision by up to 14 calendar days, if more information is needed and it will benefit you to extend the time frame. You will be sent a letter informing you of the extension and your right to file an expedited grievance. You and your provider will also receive a letter informing you of the results of the review.
Expedited “fast” pre-service Medical Care (Part C) Appeal: This is an appeal that has to be decided quickly (within 72 hours) because a standard appeal could seriously put your life or health in danger, or prevent you from regaining the greatest function. Aspire Health Plan can extend the decision by up to 14 calendar days, if more information is needed and it will benefit you to extend the time frame. You and your provider will receive a letter about the extension and the right to file an expedited grievance. You and your provider will also receive a phone call about the decision as well as a letter outlining the results of the review. If a service was already received and only a claim payment is being appealed, a “fast” review cannot be given.

Medicare Part B Prescription Drugs: If you are appealing the denial of coverage for injectable drugs administered in a physician’s office or via home infusion and certain vaccinations, or for the denial of diabetic testing supplies, then your case will be handled as a Part B Appeal. Please see Chapter 4 of your Evidence of Coverage document for a list of drugs that are covered under Part B.

There are different timelines for Part B Appeal reviews and decisions:

Standard Part B Drug: A decision can be made as quickly as your health requires, but no later than 7 calendar days after receiving the request. Please note that for this type of appeal, Aspire Health Plan cannot take extra time to make a decision for a Medicare Part B drug.
Expedited Part B Drug: This is an appeal that has to be decided quickly, within 72-hours after receiving the request. Please note that for this type of appeal, Aspire Health Plan cannot take extra time to make a decision for a Medicare Part B drug.

To request a Medical Care (Part C) or Part B Prescription Drug Appeal or to check on the status of an in-process appeal, you may contact us:

Call
Toll-free: (855) 570-1600 (TTY 711)
Local: (831) 574-4938 (TTY 711)
Calls to these numbers are free.

Hours of operation are:
8 a.m. to 8 p.m., 7 days a week

Fax
(831) 920-5903

Write
Aspire Health Plan Attn:
Appeals and Grievance Department
10 Ragsdale Drive, Suite 101
Monterey, CA 93940

Forms
Appeal and Grievance Form (PDF): English | Español

Medical Care Coverage Decisions

A medical care coverage decision is a determination we make about your health care benefits, coverage, or the amount we will pay for a medical service. Coverage decisions may include whether a service is covered, requires prior authorization, or qualifies as medically necessary under your plan.

For more information about medical care coverage decisions and what to do if you disagree with a decision, please refer to Chapter 9 of your Evidence of Coverage, “What to Do If You Have a Problem or Complaint (Coverage Decisions, Appeals, and Grievances).” You may also contact us using the phone number below if you have questions about the coverage decision process.

Requesting Clinical Guidelines

Aspire Health Plan uses evidence-based clinical guidelines when making medical necessity and coverage determinations. If you would like to review a specific guideline, please call us using the number below and provide the name of the guideline you are requesting (for example, R-0007 Heart Failure Referral Management).

A Customer Service Representative will assist you in obtaining a unique access password that will allow you to view the requested guidelines online. Once you have your password, you can access the guideline at:

Clinical Guideline Review:
https://aspire.access.mcg.com/

Clinical guidelines are also available through the Member Portal and Provider Portal.

Call
Toll-free: (855) 570-1600 (TTY 711)
Local: (831) 574-4938 (TTY 711)
Calls to these numbers are free

Hours of operation are:
8 a.m. to 8 p.m., 7 days a week

Fax
Toll-free: (855) 519-5769
Local: (831) 574-4939

Write
Aspire Health Plan Attn:
Appeals and Grievance Department
10 Ragsdale Drive, Suite 101
Monterey, CA 93940

Forms
Authorization Request Form (PDF): English | Español

Other Resources and Assistance

If you need additional assistance with a complaint, coverage decision, or appeal, the following resources are available to help:

Medicare

You may file a complaint directly with Medicare or contact Medicare for assistance.

Phone: 1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048

You may also use Medicare’s standard forms instead of the forms provided on this website, when applicable.

Quality Improvement Organization (QIO)

A Quality Improvement Organization (QIO) is an independent group of physicians and other health care professionals contracted by the federal government to help ensure Medicare beneficiaries receive high-quality health care.

You may contact Commence Health, the QIO serving Medicare beneficiaries in California, if:
You have concerns about the quality of care you received.
You believe your hospital coverage is ending too soon.
You believe coverage for your home health care, skilled nursing facility (SNF) care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services is ending too soon.
You would like assistance with a quality-of-care complaint.

For more information or to contact Commence Health, please visit their website or call the contact number listed in your Evidence of Coverage.

Need Help?

If you have questions about grievances, coverage decisions, appeals, or your Medicare rights, please contact Aspire Health Plan Customer Service using the phone number listed below. We are available to help guide you through the process and answer your questions.

COMMENCE HEALTH

Call
(877) 588-1123 about hospital stay, home health care, skilled nursing facility care or Comprehensive Outpatient Rehabilitation Facility (CORF) services and quality of care grievances.

7 days a week, 24 hours a day

TTY : 711
7 days a week, 24 hours a day

Write
BFCC-QIO Program
Commence Health
PO Box 2687
Virginia Beach, VA 23450

Website
www.commencehealthqio.cms.gov/en

Reports on Appeals and Grievances

To obtain reports on the aggregate number of appeals, grievances, and exceptions filed with Aspire Health Plan, please contact Customer Service. Following is Information on how to reach Customer Service.

Call:
Toll-free: (855) 570-1600 (TTY 711)
Local: (831) 574-4938 (TTY 711)
Calls to these numbers are free

Address:
Aspire Health Plan
10 Ragsdale Dr, Suite 101
Monterey, CA 93940

Prescription Drug Appeals

A Prescription Drug Appeal must be requested within 65 calendar days from the date on the Prescription Drug Coverage Decision notice. If you have a good reason for missing this deadline, we may give you more time. Examples of good cause may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.

There are different time frames for Prescription Drug Appeals reviews and decisions:

Standard Prescription Drug Appeal: Aspire Health Plan must make a decision as quickly as your health requires, but no later than 7 calendar days after receiving the request. You will receive written notification of the decision. If a decision could not be made within 7 days, the appeal will automatically be sent within 24 hours to an Independent Review Entity for their review and decision.
Expedited “Fast” Prescription Drug Appeal: This is an appeal that has to be decided quickly, within 72 hours of receiving the request. This is used when a standard appeal could seriously put your life or health in danger, or prevent you from regaining the greatest function. A provider is the most suitable person to decide if a “fast” rather than a standard review is appropriate. If a decision could not be made within 72 hours, the appeal will automatically be sent within 24 hours to an Independent Review Entity for their review and decision. An appeal will not be expedited if you already received the drug and are asking to be paid back.

To request a Prescription Drug Appeal or to check on the status of an in-process appeal, you may contact us:

Call
Toll-free: (888) 495-3160 (TTY 711)
Calls to this number are free.
This is a 24-hour line.

Fax
(858) 790-6060

Write
MedImpact Healthcare Systems
Attn: Prior Authorization
10181 Scripps Gateway Ct.
San Diego, CA 92131

Forms
Online: Requests for Prescription Drug Appeals
Medicare’s Redetermination Request Form (PDF): English | Español

Prescription Drug Coverage Decisions and Exceptions

You can ask Aspire Health Plan to make a coverage decision or “exception” to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Aspire Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
You can ask us to provide a higher level of coverage for your drug. For example, if your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier subject to the tiering exceptions process instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier.

Generally, Aspire Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement.

You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.

To request a Prescription Drug Coverage Decision or Exception or to check on the status of an in-process decision, you may contact us:

Call
Toll-free: (888) 495-3160 (TTY 711)
Calls to this number are free.
This is a 24-hour line.

Fax
(858) 790-7100

Write
MedImpact Healthcare Systems
Attn: Prior Authorization
10181 Scripps Gateway Ct.
San Diego, CA 92131

Forms
Online: Requests for Prescription Drug Coverage
Request for Medicare Prescription Drug Coverage Determination (PDF): (Last Revised 9/2019) English | Español

National Coverage Determination (NCD)

A National Coverage Determination (NCD) is a decision made by the Centers for Medicare & Medicaid Services (CMS) regarding whether Medicare will cover a particular medical item, service, treatment, or technology nationwide. NCDs help ensure that Medicare beneficiaries across the country receive consistent coverage for the same services, regardless of where they live.

CMS develops NCDs based on a thorough review of medical evidence, clinical research, and expert recommendations to determine whether a service is considered reasonable and necessary for the diagnosis or treatment of an illness or injury. When CMS issues a new NCD or updates an existing one, Medicare Advantage plans, including Aspire Health Plan, must follow the federal coverage requirements.

NCDs help:

Promote consistent Medicare coverage standards across the country.
Ensure coverage decisions are based on the latest clinical evidence and medical research.
Provide guidance to health care providers regarding Medicare-covered services.
Establish national rules for Medicare reimbursement and payment.
Help members better understand which services, treatments, and medical technologies are covered by Medicare.

When applicable, Aspire Health Plan uses National Coverage Determinations along with Medicare regulations, Local Coverage Determinations (LCDs), and other clinical guidelines when making coverage decisions.

To learn more about National Coverage Determinations or to review current Medicare coverage policies, visit the CMS Medicare Coverage Database or contact Aspire Health Plan Customer Service for assistance.

Give us a call

Prospective Members
Toll-free: (866) 798-1530 (TTY 711)

Current Members
Toll-free: (855) 570-1600 (TTY 711)
Local: (831) 574-4938 (TTY 711)

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Terms and Conditions

Aspire Health is a Medicare Advantage HMO plan sponsor with a Medicare contract. Enrollment in Aspire Health depends on contract renewal.

Medicare beneficiaries may also enroll in Aspire Health through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. Every year, Medicare evaluates plans based on a 5-star rating system. For accommodation of persons with special needs at meetings call 1-855-570-1600 (TTY: 711) Other Providers are available in our network. Out-of-network/non-contracted providers are under no obligation to treat Aspire Health members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1- 877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.

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