Exceptions & Appeals
File an Appeal
You may file an appeal if you want us to reconsider a decision we have made about your coverage. Examples of appeals include:
- Our decision not to cover a drug or medical benefit
- Our decision not to reimburse a medical service or a drug you paid for
- Our denial of a coverage determination
For more information about filing an appeal, please read Important Plan Information or you can call us at 1-844-214-8633.
File a Grievance
A grievance is a type of complaint you can make if you’re unhappy with something related to the quality of care or services you receive. Problems related to coverage, payment, or denial of services are handled through an appeal or initial determination.
You may file a grievance if you are dissatisfied with:
- The quality of service or care you received
- The behavior or attitude of our staff or contracted providers
- Difficulties getting timely appointments or long wait times
- Waiting too long for your prescriptions to be filled
- Feeling that you are being encouraged to leave the plan (disenroll)
- Our failure to respect your rights as a member
- Difficulty understanding our written materials
- Our decision not to expedite (fast-track) your request for a coverage decision or appeal
- Our failure to respond to your request within the required time frame
If you have a grievance, you can submit it at any time within 60 calendar days of the incident. You may file it by phone, mail, or fax. We will respond to your grievance in writing within 30 calendar days, unless we need more time and you agree to the extension.
How to Obtain an Aggregate Number of Grievances, Appeals, & Exceptions
You have the right to request the number of appeals and the number of quality of care grievances received by Abilis Health Plan (HMO SNP) during a plan year.
Appoint a Representative
You or someone you name may file a complaint (Grievance) or Appeal for you. The person you name would be your “appointed representative”. You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act on your behalf. You may call Member Services to learn how to name your appointed representative.
To appoint a representative, fill out this form. Once you have filled out the form, you may print and mail the form to:
Abilis Health
805 N Whittington Pkwy
Louisville, KY 40222
FAX: 800-880-3263
Ending Your Abilis Health Benefits
Ending your membership with Abilis Health Plan may be voluntary (your own choice) or involuntary (not your own choice). If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends.
Your disenrollment will usually be effective on the first day of the month after we receive your request to end your membership. You can choose another Medicare health plan or Original Medicare. Your enrollment in your new plan will begin on the first day of the month after you end your enrollment with us. For more complete information about disenrolling from Abilis Health, you can do any of the following:
- See your Evidence of Coverage
- Call Member Services
Read the Medicare & You Handbook. Everyone with Medicare receives a copy of Medicare & You each fall. Those new to Medicare receive it within a month after first signing up. You can also download a copy from the Medicare website. Or you can order a printed copy by calling Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Calls to these numbers are free.