Submit Complaints


Full Name*

Member ID*

Date appeal was filled*

Mail address*

Email address*

Phone Number*

Date of initial denial

Date that you need the service, equipment or payment

Denied service, equipment or payment

Provider who will be rendering the service or equipment

Comments*

I certify all information is accurate.



What is a Part D Grievance?

Any complaint or dispute, other than one that involves a coverage determination, Low Income Subsidy Determination (LIS) or Late Enrollment Penalty Determinations (LEP), expressing dissatisfaction with any aspect of the operations, activities, or behavior of Constellation Health, regardless of whether remedial action is requested. A grievance may also include a complaint that Constellation Health refused to expedite a coverage determination or redetermination.

Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item. A beneficiary or their representative may make the complaint or dispute, either orally or in writing, to a Medicare health plan, provider, or facility.

What types of problems might lead to your filing a grievance?

  • General dissatisfaction
  • Timeliness of services.
  • Interpersonal aspects of care, such as rudeness by a provider or staff member.
  • Difficulty getting through Constellation Health by the telephone.
  • A plan's benefit design
  • A plan sponsor's failure to issue a decision in a timely manner
  • A plan sponsor's denial of an enrollee's request for an expedited coverage determination or expedited re-determination.
  • 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 should 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:

Constellation Health
Compliance Department
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 a coverage 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:

Livanta
BFCC-QIO Program
9090 Junction Drive, Suite 10 Annapolis
Junction, MD 20701

Phone: 1-866-815-5440
TTY: 1-866-868-2289

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)
Executive Director
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 can 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
Compliance Department
PO Box 364547
San Juan, PR 00936-4547

Coverage decision

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your services and prescription drugs. If you disagree with a coverage decision, you can make an appeal.

How to request an organization/coverage determination from Constellation Health?

Beneficiaries can request an organization/coverage determination the following ways:

Call to:

  • 1-866-714-0724 (Toll Free)
  • 787-304-4040 (Metro Area)
  • 1-866-805-7777 (TTY – Hearing Impaired)
  • Send written request via fax to: 787-773-6420

Send written request by mail to the following address:

Constellation Health, LLC.
PO Box 364547
San Juan, PR 00936

Our hours of operations are Monday through Friday from 8:00 a.m. to 8:00 p.m.

For certain drugs, you will need to get approval from Constellation Health before we will agree to cover the drug for you. This process is called prior authorization. If you do not get this approval, your drug might not be covered by the plan.

What is a Part D Appeal?

An appeal is a way of ask Constellation Health to review and change a coverage decision we have made. Your appeal is handled by different reviewers than those who made the original unfavorable decision to check that all rules were followed correctly. When we have completed the review we will give you our decision.

How can I get help with a coverage decision or an appeal?

There are resources available to you if you decide to ask for any kind of coverage decision or appeal a decision:

Call Customer Service at:

  • 1-866-714-0724 (Toll Free)
  • 787-304-4040 (Metro Area)
  • 1-866-805-7777 (TTY – Hearing Impaired)

Send written request via fax to: 787-773-6420

Send written request by mail to the following address:

Constellation Health
PO Box 364547
San Juan, PR 00936

Our hours of operations are Monday through Friday from 8:00 a.m. to 8:00 p.m.

  • Get free help from an independent organization that is not connected with our plan, State Health Insurance Assistance Programs that you can contact in your state.
  • Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision or a Level 1 Appeal on your behalf.
  • You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal

What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask us to make an exception or coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved.

How do I ask for a coverage decision or an exception?

You, your representative, or your doctor or prescriber can request a coverage decision or exception. You can request your exception by calling, writing or sending a fax to us. Click Contact us for our contact information.

If you are requesting an exception, you may send in a written request along with a supporting statement from your doctor or prescriber that lists the medical reasons for the drug exception you are requesting. You and your doctor or prescriber may use the Request for Medicare Prescription Drug Coverage Determination Form provided in the link below, or you may send us any form of written request and supporting statement.

Your doctor or prescriber can fax or mail the statement to us. Click here to use the Request for Medicare Prescription Drug Coverage Determination Form for your exception request and supporting statement.

A fast coverage decision or expedited decision can be requested, and may depend on the nature of the situation, if your health or ability to function is at risk. Please call or fax us if you need medication so we can begin the process quicker.

These are the timeframes for a decision to be made:

  • Standard coverage decision - within 72 hours after we receive your doctor's statement.
  • Fast or expedited coverage decision - within 24 hours after we receive your doctor's statement.

How do I request a Redetermination of the coverage decision?

If you have received documentation from us regarding our denial of your request for redetermination, you have the right to ask for an independent review (appeal) of our decision. If your case involves an exception request and your physician or other prescriber did not already provide your plan with a statement supporting your request, your physician or other prescriber must provide a statement to support your exception request to attach to your appeal request.

You must mail or fax your written request to the independent reviewer at:

MAXIMUS Federal Services
3750 Monroe Ave., Suite #703
Pittsford, NY 14534-1302
Fax: 1-585-425-5301
Toll free fax: 1-866-825-9507
Toll free customer service: 1-877-456-5302

Late Enrollment Penalty Reconsiderations should be directed to:

MAXIMUS Federal Services
3750 Monroe Ave., Suite #704
Pittsford, NY 14534-1302
Fax: 1-585- 869-3330
Toll free fax: 1-866- 589-5241
Toll free customer service: 1-877-456-5302