Submit a Grievance
What is a Part C Grievance?
A grievance is any complaint, other than one that involves a request for an initial determination or an appeal, expressing dissatisfaction with the manner in which Constellation Health provides health care services, regardless of whether any remedial action can be taken. In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service or procedure. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of health care.
Grievances do not involve problems related to approving or paying for Part C medical care or services, problems about having to leave the hospital too soon, and problems about having Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending too soon.
What types of problems might lead to your filing a grievance?
- General dissatisfaction
- Problems with the quality of the medical care or services you receive, including quality of care during a hospital stay.
- Difficulty getting through on the telephone.
- If you feel that you are being encouraged to leave (disenroll) from the Plan.
- Change in premiums or cost sharing arrangements from one contract to the next.
- Interpersonal aspects of care, such as rudeness by a provider or staff member.
- Failure to respect an enrollee’s right.
- Timeliness of services.
- Disagreement with Constellation Health’sDecision to grant an extension or not to expedite the organization determination and/or appeal. In this case your request will be treated as an expedite grievance.
- We don’t give you a decision within the required time frame.
- If you have one of these types of problems and want to make a complaint, it is called “filing a grievance.”
Who may file a grievance?
You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. 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 for you 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.
To learn how to name your representative, you may call Customer Service at 1-866-714-0724 (Toll Free) or 787-304-4040 (Metro Area). TTY users must call 1-866-805-7777. Our hours of operations are from Monday through Sunday from 8:00 a.m. to 8:00 p.m. You may also fill out an Appointment of Representative Form and submit it along with your grievance. Click here to access the Appointment of Representative Form or call Customer Service and ask them to mail it to you. The form gives that person permission to act on your behalf.
Constellation Health will confirm that the person filing the grievance is the authorized representative. If we cannot confirm this, we will send a letter to you requesting the Appointment of Representative Form and establishing that the timeframe for acting on a grievance will start 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.
How can I file a grievance?
If you have a complaint, both you and your representative may call us at 1-866-714-0724 (Toll Free) or 787-304-4040 (Metro Area). TTY users must call 1-866-805-7777. Our services hours are from Monday through Sunday from 8:00 a.m. to 8:00 p.m. We will try to resolve your complaint by phone.
If you should request a response in writing, file a grievance in writing, or if your complaint is regarding the quality of care, we will respond to you in writing. If we are unable to resolve your complaint by telephone, we have a formal procedure for reviewing your complaints. We call this the grievance procedure.
You may file a grievance in writing by sending it via fax at 787-773-6421, through the website, by delivering it in person in our office, or by mailing in your request to:
PO Box 364547
San Juan, PR 00936-4547
The grievance must be submitted within 60 days of the event. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.
To file a complaint about your Medicare Plan directly with CMS you can call 1-800-Medicare or click here.
Fast “Expedited” Grievances
In instances, you are entitled to request for a “fast grievance”. That means that we will answer your grievance in 24 hours. You may file a fast grievance and Constellation Health will have to respond within 24 hours of your request, if Constellation Health extends the period for making an organizational determination or reconsideration. You may also file a fast grievance and Constellation Health will have to respond within 24 hours of your request, if our Plan does not grant the expedited request for the organizational determination or reconsideration.
What if I have a complaint about the Quality of Care?
For quality of care problems, you may also complain to the Quality Improvement Organization (QIO). You may complain about the quality of care received, including care during a hospital stay. You may complain to us using the grievance process, to the Quality Improvement Organization (QIO), or both. If you file with the QIO, we must help the QIO resolve the complaint. You may complain about the quality of care received, including care during a hospital stay. You may complain to us using the grievance process, to the Quality Improvement Organization (QIO), or both. If you file with the QIO, we must help the QIO resolve the complaint.
In Puerto Rico, the contracted organization is Livanta. You or your authorized representative can contact Livanta by phone or in writing:
9090 Junction Drive, Suite 10 Annapolis
Junction, MD 20701
Other Rights for Dual Eligible Enrollees (Medicaid and Medicare)
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). To do so, the enrollee, including his or her representative, must write within 30 days from receipt of the determination of the Plan to the following address:
Administración de Servicios de Salud (ASES)
PO Box 195661
San Juan, PR 00919-5661
The enrollee 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 claim or situation why he or she is requesting the hearing and send a copy of the final decision issued by Constellation Health.
How to obtain an aggregate number of grievances, appeals, and exceptions filed with Constellation Health?
To obtain an aggregate number of grievances, appeals and exceptions filed with the plan, please call us at 1-866-714-0724 (Toll Free) or 787-304-4040 (Metro Area). TTY users should call 1-866-805-7777. Our hours of operations are from Monday through Friday from 8:00 a.m. to 8:00 p.m. You can also write us to the following address:
Constellation Health, LLC.
1064 Ponce de León Avenue
San Juan, PR 00907
How to request an organization/coverage determination from Constellation Health?
Beneficiaries can request an organization/coverage determination the following ways:
- 1-866-714-0724 (Toll Free)
- 787-304-4040 (Metro Area)
Send written request via fax to:
Send written request by mail to the following address:
Constellation Health, LLC.
PO Box 364547
San Juan, PR 00936-47
Our hours of operations are Monday through Friday from 8:00 a.m. to 8:00 p.m.
To file an organization/coverage determination about your Medicare Plan directly with CMS you can call 1-800-Medicare or click here.
What If I Don’t Agree With This Decision?
You have the right to appeal. File your appeal in writing within 60 calendar days after the date of this notice. We can give you more time if you have a good reason for missing the deadline.
Who May File An Appeal?
You or your treating physician may file an appeal. Or you may name a relative, friend, advocate, attorney, doctor (other than your treating physician), or someone else to act as your representative. Others also already may be authorized under State law to act for you.
You can call us at 787-304-4040 or 1-866-714-0724 to learn how to name your representative. If you have a hearing or speech impairment, please call us at TTY users should call 787-999-6203 or 1-866-805-7777. We are open 7 days a week, 8:00 A.M. – 8:00 P.M.
If you want someone to act for you, you and your representative must sign, date, and send us a statement naming that person to act for you.
There are two kinds of appeals you can file:
1. Standard (30 days) - You can ask for a standard appeal. We must give you a decision no later than 30 days after we get your appeal. (We may extend this time by up to 14 days if you request an extension, or if we need additional information and the extension benefits you.)
2. Fast (72 hour review) - You can ask for a fast appeal if you or your doctor believe that your health could be seriously harmed by waiting up to 30 days for a decision. We must decide on a fast appeal no later than 72 hours after we get your appeal. (We may extend this time by up to 14 days if you request an extension, or if we need additional information and the extension benefits you.)
- If any doctor asks for a fast appeal for you, or supports you in asking for one, and the doctor indicates that waiting for 30 days could seriously harm your health, we will automatically give you a fast appeal.
- If you ask for a fast appeal without support from a doctor, we will decide if your health requires a fast appeal. We will notify you if we do not give you a fast appeal, and we will decide your appeal within 30 days.
What do I include with my appeal?
Your written request should include: your name, address, member number, reasons for appealing, and any evidence you wish to attach. You may send in supporting medical records, doctors' letters, or other information that explains why we should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person.
How Do I File An Appeal?
For a Standard Appeal: Mail or deliver your written appeal to the address below:
PO BOX 360493
San Juan PR 00936
For a Fast Appeal: Contact us by telephone or fax:
787-304-4040 or 1-866-714-0724
What Happens Next?
If you appeal, we will review our decision. After we review our decision, if any of the services you requested are still denied, Medicare will provide you with a new and impartial review of your case by a reviewer outside of your Medicare health plan. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.
- 1-866-714-0724 (Libre de costo)
- 787-304-4040 (Área Metro)
- 1-866-805-7777 (TTY – Audioimpedidos)
Other Resources to Help You:
Medicare Rights Center:
Toll Free: 1-888-HMO-9050
Elder Care Locator
Toll Free: 1-800-677-1116