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Appeals & Grievances

 

We encourage you to let us know right away if you have questions, concerns, or problems related to your covered services or the care you receive. If you have a grievance call Member Services at the phone number below.

Call us

 in the Ohio Valley or Mountaineer Region at 1.877.847.7907 (TTY/TDD: 1.800.622.3925) or in the HomeTown Region at 1.800.426.9013 (TTY/TDD: 1.877.236.2291).

Mail or Fax

 a written request/form to:

The Health Plan
Ohio Valley or Mountaineer Region
52160 National Road East
St. Clairsville, OH 43950
FAX: 740.699.6163

or

The Health Plan
HomeTown Region
100 Lillian Gish Blvd.
PO Box 4816
Massillon, OH 44648
FAX: 330.830.5634

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Exception, Appeals and Grievances Forms

You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination. Please call Member Services Ohio Valley or Mountaineer Region at 1.877.847.7907 (TTY/TDD: 1.800.622.3925) or HomeTown Region at 1.800.426.9013 (TTY/TDD: 1.877.236.2291).

When asking for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests.

• If you are a provider on behalf of a SecureCareHMO or SecureChoicePPO enrollee requesting a Part D prescription coverage determination, use the Medicare Part D Coverage Determination Request Form (141k)
• If you are a SecureCareHMO or SecureChoicePPO enrollee requesting a Part D prescription coverage determination, use the Request for Medicare Prescription Drug Coverage Determination Form (19k).
• If appointing a representative in connection with a claim, please complete the CMS Appointment of Representative Form (67k)

For complete information on Grievance, Coverage Determination, and Appeals Information, please refer to your Evidence of Coverage with RX plan document, Chapter 9 for SecureCareHMO and SecureChoicePPO or Evidence of Coverage without RX plan document, Chapter 7 for SecureCareHMO and SecureChoicePPO.

 

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