Coverage Decisions for Medical Care

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. You can also find more information in Chapter 9 of the Evidence of Coverage; What to do if you have a problem or complaint (coverage decisions, appeals, complaints). This chapter tells you step-by-step what to do if you are having problems or concerns as a member of our plan.

Here is how to contact us when you are asking for a coverage decision about your medical care:

Contact Member Services

• Call toll-free: 1.833.76SECUR (1.833.767.3287) or TTY 711 for any questions or assistance with your plan. Our hours are Monday - Sunday, 8 a.m. - 8 p.m. During certain times of the year, we may use alternative technologies to answer your call on weekends and federal holidays. Member Services also has free language interpreter services available for non-English speakers.
• Fax: 813.357.5352
• Write: 4200 W. Cypress Street, Suite 690, Tampa, FL 33607

Coverage Determination for Part D Prescription Drugs

A coverage determination is a decision we make about your benefits and coverage or about the amount we will pay for your Part D prescription drugs.  You can also find more information in Chapter 9 of the Evidence of Coverage; What to do if you have a problem or complaint (coverage decisions, appeals, complaints). This chapter tells you step-by-step what to do if you are having problems or concerns as a member of our plan.

Here’s how to contact us when you are asking for a coverage determination about your Part D prescription drugs:

• Call toll-free: 1.866.270.3877 or TTY 711, 24 hours a day/7 days a week, except Thanksgiving and Christmas Day.
• Fax: 1.855.688.8552.
• Write: P.O. Box 1039, Appleton, WI 54912-1039

Prescription Determination Form

Prescription Redetermination Form

How to File an Appeal

1. Contact our Appeals Department to request a review:

• Phone: 1.833.76SECUR (1.833.767.3287)
• TTY: 711
• Fax: 813.357.5352
• Mail:
  SECUR Health Plan
  Appeals and Grievances Department
  4200 W. Cypress Street, Suite 690
  Tampa, FL 33607

2. Include your name, member ID number, and details of the service or decision you're appealing.
3. Appeals must be filed within 65 days of the date on the initial decision notice or explanation of payment (EOP).

If you want to file an appeal regarding the denial of a Part D drug coverage, please follow these steps to file:

• Call 866.270.3877, TTY users can call 711.
• Fax: 844.268.9791
• Mail:
  Navitus Health Solutions
  Grievance & Appeals
  P.O. Box 999
  Appleton, WI 54912-0999

How to File a Grievance

• Call 1.833.76SECUR (1.833.767.3287), TTY users can call 711.
• Fax: 833.852.2651
• Mail:
  SECUR Health Plan
  Appeals and Grievances Department
  4200 W. Cypress Street, Suite 690
  Tampa, FL 33607

You can also file a grievance in person, by mail, or by fax.

Grievances can be filed at any time and do not have to be related to coverage decisions.

If you have a grievance specifically with regard to Part D and your drug coverage, please follow these steps to file:

• Call 866.270.3877, TTY users can call 711.
• Fax: 844.268.9791
• Mail:
  Navitus Health Solutions
  Grievances & Appeals
  P.O. Box 999
  Appleton, WI 54912-0999

Medicare Complaint Form

You also have the right to file a complaint regarding problems with SECUR Health Plan directly with Medicare. This can be done by submitting a complaint form online: Medicare Complaint Form

Medicare takes your concerns seriously and will use this information to help improve the quality of the I-SNP Medicare program. For help form Medicare related to your concerns, please call 1.800.Medicare (1.800.633.4227). TTY users can call 1.877.486.2048. Medicare is available 24 hours a day, seven days a week, except for some federal holidays.

Timeframes for Appeals and Grievances:

• Standard Appeals: We will notify you of our decision within 30 calendar days of receiving your request.
• Expedited Appeals: If your health requires a faster decision, we will respond within 72 hours.
• Grievances: We will acknowledge your grievance and aim to resolve it within 30 calendar days.
• Expedited Grievances: If your grievance is related to a decision not to grant your request to expedite or extend an initial determination or appeal, or if you have not obtained your medication, the plan will resolve your grievance within 24 hours.

What is a Medicare Beneficiary Ombudsman?

The Medicare Beneficiary Ombudsman is a person who reviews and helps you with your Medicare complaints. They make sure information about your Medicare coverage, your Medicare rights and protections, and how you can get issues resolved is available to you. To contact the Medicare Beneficiary Ombudsman, call 1-800-MEDICARE, or click https://www.medicare.gov/basics/your-medicare-rights

Non-Contracted Provider Appeal Requests

Non-Contracted Providers may submit requests for appeal by mail or fax. All requests for appeal must be submitted within 60 calendar days from the date of the remittance. Please send your request for appeal, signed Waiver of Liability Statement and any supporting documentation to the following address or fax number:

• Mail:
  SECUR Health Plan
  Appeals and Grievances Department
  4200 W. Cypress Street, Suite 690
  Tampa, FL 33607
• Fax: 833-852-2651

Waiver of Liability

Your Right as a SECUR Health Plan Member

You have the right as a member to obtain a listing of Appeals and Grievances filed against SECUR Health Plan. Our plan reports this information to the Center for Medicare and Medicaid Services quarterly. This information is available to you by visiting www.medicare.gov. You may also call our Member Services department at 1.833.767.3287 for assistance in obtaining this information.