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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
Exception, Appeals and Grievances Forms
- Grievance Form - SecureCare,
SecureChoice or SecureFreedom
(100k) - Medicare Part D Coverage
Determination Request Form
(141k)
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.
- CMS Appointment of Representative Form
(67k)
For complete information, please refer to your Evidence of Coverage document, located on the Helpful Resources page.
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