Grievance & Appeals Information
This page contains grievance and appeals information that can be found in the Evidence of Coverage for Piedmont Select Medicare Option One (PPO) and Piedmont Select Medicare Option Two (PPO).
For a complete copy of the Evidence of Coverage click below:
2012 Evidence of Coverage
Piedmont Select Medicare Option One
(see Chapter 9, pg. 139 for the Grievance and Appeals Section)
Piedmont Select Medicare Option Two
(see Chapter 9, pg. 139 for the Grievance and Appeals Section)
Forms you may need:
1. Appointment of Representative Form CMS-1696
If a beneficiary would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on his or her behalf, the beneficiary and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request.
2. Request for a Medicare Prescription Drug Coverage Determination
A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this model form to request a coverage determination from a plan sponsor.
3. Coverage Determination Request Form for Physicians
This form was developed by AHIP, the AMA, and other entities to provide prescribers with a form to be used to request a coverage determination or exception, support a tiering or formulary exception request, or request prior authorization. It may be completed by an enrollee's prescriber and mailed or faxed to the enrollee's plan sponsor.
4. Redetermination Request Form
A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination from a plan sponsor.
5. Medicare Complaint Form
The above link allows you to submit feeback about your Medicare health plan or prescription drug plan.
Contact information:
For prescription drug grievances and appeals call 24 hours a day, 7 days a week at:
- 1-866-494-9927
- TTY users should call 1-866-236-1069
You may submit a grievance or appeal via fax at 1-866-217-3353. Or you may send it to us in writing to:
Piedmont Select Medicare Option One
Piedmont Select Medicare Option Two
Prescription Drug Plans Grievance/Appeals Department
P.O. Box 280500
Nashville, TN 37228
Contact information:
For medical grievances and appeals call:
- 434-947-3671
- 1-877-210-1719 (toll free)
- TTY users should call 1-877-295-1454
Customer Service is available from 8:00 a.m. to 8:00 p.m., seven days a week from October 15 through February 14. From February 15 until the next Annual Enrollment Period, Customer Service is available from 8:00 a.m. to 8:00 p.m., Monday through Friday. Our local office is open for walk-in customer assistance from 8:30 a.m. to 5:00 p.m., Monday - Friday, except for holidays at 1937 Thomson Drive, Lynchburg, VA, 24501.
You may submit a grievance or appeal via fax at 1-434-947-3670. Or you may send it to us in writing to:
Piedmont Medicare Advantage
Grievance/Appeals Dept.
1937 Thompson Drive
Lynchburg, VA 24501
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H1659_WebRev2012 CMS Approved 12302012
Last updated 01/03/2012
