Appeals and Grievances

If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision, make an appeal or file a grievance. There may be someone who is already legally authorized to act as your representative under State law. If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services and ask for the “Appointment of Representative” form. This form can be found on Medicare's website or by clicking here.

The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services.

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

• Call 1-888-657-4170 (TTY 711), calls to this number are free. Our hours are Monday - Friday, 8 am - 8 pm. 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 352-515-5975
• Write Ultimate Health Plans, Inc., PO Box 3459, Spring Hill, FL 34606

An appeal is a formal way of asking us to review and change a coverage decision we have made.

Here’s how to contact us when you are making an appeal about your medical care:

• Call 1-888-657-4170 (TTY 711), calls to this number are free. Our hours are Monday - Friday, 8 am - 8 pm. 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 1-800-313-2798
• Write Ultimate Health Plans, Inc., Appeals & Grievances Department, PO Box 6560, Spring Hill, FL 34611

You can make a complaint about us or one of our network providers, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about the plan’s coverage or payment, you should look at the section above about making an appeal.)

You can learn more about the CMS Model Prescription Drug Determination Request Form by clicking here.

Here’s how to contact us when you are making a complaint about your medical care:

• Call 1-888-657-4170 (TTY 711), calls to this number are free. Our hours are Monday - Friday, 8 am - 8 pm. 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 1-800-313-2798
• Write Ultimate Health Plans, Inc., Appeals & Grievances Department, PO Box 6560, Spring Hill, FL 34611
• Medicare Website: To submit an online complaint to Medicare, please click here.

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your Part D prescription drugs.

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

• Call 1-800-311-7517 (TTY 711), calls to this number are free. Our hours of Operation: 24 hours a day, 7 days a week.
• Fax 1-844-403-1029
• Write OptumRx, Prior Authorization Department, PO Box 25183, Santa Ana, CA 92799

To file an appeal (request for redetermination) for a Medicare prescription drug denial, please have your provider complete the form below:

And/Or

Contact us in making an appeal about your Part D prescription drugs:

• Call 1-800-311-7517 (TTY 711), calls to this number are free. Our hours of Operation: 24 hours a day, 7 days a week.
• Fax 1-844-403-1029
• Write OptumRx Prior Authorization Department, PO Box 25183, Santa Ana, CA 92799

You can make a complaint about us or one of our network pharmacies, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about the plan’s coverage or payment, you should look at the section above about making an appeal.)

Here’s how to contact us when you have complaints about Part D prescription drugs:

• Call 1-800-311-7517 (TTY 711), Calls to this number are free. Our hours of Operation: 24 hours a day, 7 days a week.
• Fax 1-800-313-2798
• Write Ultimate Health Plans, Inc., Appeals & Grievances Department, PO Box 6560, Spring Hill, FL 34611
• Medicare Website: You can also submit a complaint about our plan directly to Medicare. To submit an online complaint to Medicare, click here.

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 all people with Medicare. To contact the Medicare Beneficiary Ombudsman, call 1-800-MEDICARE, or click here.

A non-contracted provider, on his or her own behalf, is permitted to file a standard appeal (in writing) for a denied claim only if the provider completes a Waiver of Liability statement, which states that the non-contracted provider will not bill the enrollee regardless of the outcome of the appeal. The purpose of this statement is to ensure that the member will not be held financially liable if the provider loses the appeal.

You must submit your request to file an appeal and your Waiver of Liability Statement within 60 days from the remittance notification. Please send the signed form and supporting documentation to the following address or fax number: