Appeals and Grievances
Your satisfaction is our priority so if you are having a problem getting the care or service you desire, we want to talk with you. Please call our Member Services number at 1-844-867-1156 and we will do everything we can to resolve your concern. If after we talk you are still not satisfied, please reference the information below regarding your appeals and grievances rights.
Appeals and Grievances
Click the Evidence of Coverage link below and go to Chapter 9 for the process and more information on how to file a reconsideration/redetermination (appeal) or complaint/grievance. For process or status questions, you can contact us at Member Services 1-844-867-1156 (TTY/TDD: 711). For process or status questions, your provider can contact us at 1-844-867-1156
- Evidence of Coverage Trillium Advantage Pioneer Rx (PPO) - Chapter 9
- Evidence of Coverage Trillium Advantage Dual (HMO SNP) - Chapter 9
- Evidence of Coverage Trillium Advantage TLC ISNP (HMO SNP) - Chapter 9
- Evidence of Coverage Trillium Advantage TLC Community ISNP (HMO SNP) - Chapter 9
Appointing a Representative – Instructions & Form
People who want to represent a member can be appointed or authorized by the member.
A member can authorize anyone (like a relative, friend, advocate, an attorney, or a doctor) to act as his or her representative and file an appeal on his or her behalf.
A representative (or surrogate) can also be authorized by the court or act on behalf of the member in accordance with State law to file an appeal for an enrollee. A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney, or a health care proxy, or a person designated under a health care consent statute.
How to authorize a representative:
- The member must sign, date, and complete a representative form.
- The person acting on behalf of the member must sign, date and complete the same form.
- Print and complete the Appointment of Representative form. If a member is incapacitated or legally incompetent a surrogate is not required to submit an Appointment of Representative Form. The surrogate will need to give Trillium Advantage copies of the legal papers supporting his or her status as the member’s authorized representative. Trillium Advantage requires a copy of the completed and signed Appointment of Representative Form to process an appeal filed by the member’s representative. The form will be valid during the entire appeal process. The Appointment of Representative Form is valid for one year from the date indicated on the form. A member can revoke the authorization at any time.
How to Obtain an Aggregate Number of Grievances, Appeals and Exceptions Filed with Trillium Advantage
To obtain an aggregate number of Trillium Advantage grievances, appeals and exceptions, please call Member Services at 1-844-867-1156 (TTY/TDD: 711). From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m.
For help with complaints, grievances, and information requests, you can contact The Office of the Medicare Ombudsman (OMO). http://www.medicare.gov/Pubs/pdf/11173.pdf
To file a complaint directly with CMS – https://www.medicare.gov/MedicareComplaintForm/home.aspx
Last Updated: 09302016