MCS Classicare Procedure for Handling Part C or Part D Grievance

What is a Part C Grievance?

A grievance is an expression of dissatisfaction with any aspect of the operations, activities or behavior of a Plan, or its Delegated Entity in the provision of health care items, services, or prescription drugs, regardless of whether remedial action is requested or can be taken. A grievance may also include a complaint that a Plan sponsor refused to expedite an organization determination or reconsideration (appeal), and complaints regarding the timeliness, access to, and/or setting of a provided health service and/or procedure.

Grievances do not include, and is distinct from, a dispute of the appeal of an Organization Determination or a determination related to Late Enrollment Penalty (LEP). Also it does not involve issues related to approving or paying for Part C medical care or services, issues about having to leave the hospital too soon, and issues about having Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending too soon.

What types of issues might lead you to file a Part C grievance?

• General dissatisfaction
• If you feel that you are being encouraged to leave (disenroll from) the Plan.
• Change in premiums or coinsurance arrangements from one contract to the next.
• Issue with the service received from MCS Call Center.
• Issues with the quality of the medical care or services you receive, including quality of care during a hospital stay.
• Inappropriate behavior from Physicians, Nurses, Receptionists or any other staff member.
• Failure to respect an enrollee’s right.
• Issue obtaining a service when you need it or waiting to long to obtain it.
• Disagreement with MCS decision to grant an extension or not to expedite the Organization Determination and/or Appeal (This will be treated as an expedite grievance).
• We don’t provide you a decision within the required timeframe.
• We don’t provide you required notices.
• You believe our notices and other written materials are hard to understand.

What is a Part D Grievance?

A grievance is an expression of dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan sponsor or its Delegated Entity related to obtaining prescription drugs, regardless of whether remedial action is requested or can be taken. A grievance may also include a complaint that a Part D plan sponsor refused to expedite a coverage determination or redetermination (appeal) and complaints regarding the timeliness, access to, and/or setting of a provided prescription drug.

Grievances do not include a coverage determination, a Low-Income Subsidy (LIS) or Late Enrollment Penalty (LEP) determination.

What types of issues might lead you to file a Part D grievance?

• Waiting too long for prescriptions to be filled
• Difficulty with the services you receive in MCS Call center
• Problems with the quality of care or benefits you receive
• Inappropriate conduct by a pharmacist or any other staff member.
• A plan's benefit design
• We don’t provide you a decision within the require timeframe
• A plan sponsor's denial of an enrollee's request for an expedited coverage determination or expedited re-determination.

If you have one of these types of issues and want to submit a complaint, it is called “filling a grievance”.

Who may file a grievance?

You or someone you appoint as your “Authorized Representative”, may file a grievance. You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act on your behalf. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act on your behalf, who is not already authorized by the Court or under State Law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. In order to confirm your Authorized Representative, please submit the Appointment of Representative form along with your grievance.

MCS Classicare will confirm that the person filling the grievance is the authorized representative. If we cannot confirm your Representative, we will send a letter to you requesting the Appointment of Representative Form and informing that the timeframe for acting on a grievance commences when the documentation is received. If we do not receive the documentation by the conclusion of the grievance timeframe, we will notify you about the dismissal of your case.

If you have any questions on how to appoint an Authorized Representative, you may visit any of our MCS Service Centers or call MCS Classicare Call Center at 1-866-627-8183 (Toll free) or TTY 1-866-627-8182 (number for hearing impaired persons). Our service hours are from October 1st through March 31st, you can call us, 7 days of the week, from 8:00 a.m. to 8:00 p.m. From April 1st through September 30, you can call us Monday through Friday, from 8:00 a.m. to 8:00 p.m., and Saturday, from 8:00 a.m. through 4:30 p.m.

Availability of Assistance to File a Grievance

To ensure that the grievance procedure is accessible to all Members and is provided in a culturally competent manner, including those with limited English or Spanish proficiency or reading skills, and those with diverse cultural and ethnic backgrounds, MCS Classicare will provide the following services when necessary:

• TTY Line (number for the hearing impaired, 1-866-627-8182)
• Sign Language and/or Foreign Language Interpreter and Written Translation Services
• Audio Tapes, accessible electronic formats
• Braille
• Language Line Service, Inc.

Filling a grievance with our Plan

The grievance must be submitted within 60 days of the event or incident. For Dual Eligible enrollees (Medicare and Medicaid), grievance can be submitted at any time. We must address your grievance as quickly as your case requires based on your health status, but no later than thirty (30) days after receiving your grievance. We may extend the timeframe by up to 14 days if you ask for an extension, or if we justify a need for additional information and the delay is in your best interest. It could be received verbally or in writing.

Press here to obtain the Grievances Submission Form (Update: 18/5/2022)

If you have a complaint, both you and your Authorized Representative may call us at 1-866-627-8183 (Toll free) or TTY 1-866-627-8182 (the number for the hearing impaired), from October 1st through March 31st, you can call us, 7 days of the week, from 8:00 a.m. to 8:00 p.m. From April 1st through September 30, you can call us Monday through Friday, from 8:00 a.m. to 8:00 p.m., and Saturday, from 8:00 a.m. through 4:30 p.m.

If you request a response in writing, file a grievance in writing, or if your grievance is regarding a Quality of Care issue, we will respond to you in writing. You may file a grievance in writing by sending it via fax at 787-620-7765, by delivering it in person at one of MCS Service Centers, or by mailing in your request to:

MCS Advantage, Inc.
Grievances and Appeals Unit

P.O. Box 195429
San Juan PR 00919-5429

Expedite Grievances

In some cases, you are entitled to request an expedite grievance, which means that we will respond your grievance within 24 hours. You may file an expedite grievance, if our Plan extends the period for making an Initial Determination or Appeal and you don’t agree. You may also file an expedite grievance if our Plan does not grant the expedited request for an initial determination or appeal.
You may also file a complaint with Medicare at Medicare.gov/complaint

For Quality of Care issues, you have the right to file a grievance before the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)

Quality of Care grievances may be received and acted upon by the Plan, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), or both. For any grievance submitted to the BFCC-QIO, we must cooperate with the BFCC-QIO in resolving the grievance.

In Puerto Rico, the contracted organization is Livanta. You or your Authorized Representative can contact Livanta by phone or in writing:

Livanta LLC
BFCC-QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701-1105
Local telephone: 787-520-5743
Toll free number: 1- 866-815-5440
TTY (for people with hearing disabilities): 1- 866-868-2289
Fax: (855) 236-2423
Working Hours: Monday to Friday, 9:00 am to 5:00 pm
24-hour voicemail service is available

Other Rights for Dual Eligible Enrollees (Medicare and Medicaid)

You have the right to file a grievance in the Patient Advocate Office of Puerto Rico Government by calling: (787) 977-0909, 1-800-981-0031 (free of charge), TTY (787) 710-7057 or via fax (787) 977-0915.

Some of the Plan services may also be covered by Medicaid. Therefore, dual eligible enrollees may also have the right to file a Grievance or an Appeal, including requesting an Appeal of a Grievance determination, before the Government of Puerto Rico Health Insurance Administration (ASES, by its acronym in Spanish). You or your authorized representative, should request an Administrative Law Hearing via postal mail or telephone call between 120 calendars days from receipt of the determination letter of your Level 1 Appeal. The letter you receive from us, will provide you information of where to submit your Hearing request.

You must indicate his or her name, address, name of Provider or Health Care Organization where he or she received or will receive the service of the appeal, a brief description of the situation that precipitate your appeal, including a copy of the Initial Determination issued by the Plan.

Additional, for dual eligible enrollees (Medicare and Medicaid), MCS provides you a reasonable opportunity to present, in person and in writing, evidence and testimony and make legal and factual arguments regarding your appeal, considering the limited time available to present evidence sufficiently in advance of the resolution timeframe for expedite and standard appeals.