Grievance & Appeals

At PUP, we have high standards for quality care, and aim to exceed those standards for all of our Members.

Filing a Grievance

If at any time you are unhappy with the service you are receiving from our plan, you have the right to make a complaint by filing a Grievance.

This complaint process handles the following types of problems:

  • Quality of your medical care
  • You feel private information is being shared
  • Poor customer service
  • Long waiting times (at doctor appointments, pharmacies, or on the phone with Member Services)
  • Cleanliness of network clinic, hospital, or doctor office
  • Plan materials that are hard to read or understand

If any of these situations apply to you, make sure to file a grievance. It’s the only way we can properly fix the problem, so you can continue being satisfied with the care you receive from PUP.

How can I file a grievance?

Grievances must be filed within 60 days of the event or incident.

The first step is to call or write Member Services. If possible, we will answer you right away, even during the same phone call. Most complaints are answered within 30 calendar days. If you choose to put your complaint in writing, we will follow our written grievance procedure.

Fast Grievances

In certain cases, you have the right to ask for a “fast grievance”, which means we will answer your grievance within 24 hours.

Please click the links below to review the details for all grievance procedures.

For PUP Easy, PUP Elite, PUP Extra, PUP Plus and PUP Rewards, please refer to Chapter 9 of your EOC. For PUP Perks, please refer to Chapter 7.

You may also contact Member Services, Monday through Sunday from 8:00 a.m. to 8:00 p.m., at the number listed below:

  • Toll-free: 1-866-571-0693
  • TTY/TTD: 1-800-955-8771

Medicare Beneficiary Ombudsman

Medicare has a Medicare Beneficiary Ombudsman that can help you with complaints, grievances and information requests. Click here to go to the Medicare Beneficiary Ombudsman website.

You can also submit a complaint about our plan directly to Medicare. Please go to the Medicare website at www.medicare.gov. On the home page, under “Need Help?” , click on Medicare Complaint Form. Fill out the form and click on the “Submit” button.

Click here for the Medicare complaint form.

Quality of Care Problems

If you have a complaint about the quality of care you are receiving, you can also file a complaint with Florida’s Quality Improvement Organization (QIO). This organization is paid by Medicare to check on and improve the quality of care for people with Medicare. This includes all of the care received under Medicare, such as care during a hospital stay.

If you file with the QIO, we must help resolve the complaint. To learn how to contact Florida’s QIO, find your EOC by clicking the list below and refer to Chapter 2.

Appeals

If you want us to reconsider and change a Coverage Determination that has been made, you may file an appeal, (also known as a redetermination). We will handle your appeal as quickly as your case requires, based on your health status.

How long does an appeal take?

  • We will take no longer 30 calendar days (for service/coverage appeals) and 60 calendar days (for claim/co-pay appeals) after receiving your request for reconsideration.
  • An Expedited (fast) Appeal will be handled within seventy-two (72) hours.

How can I file an appeal?

You, your appointed representative or Provider may file an appeal by calling or writing:

  • For Part C (Medical) Appeals:
    • Call: 1-866-429-5352 (TTY/TDD: 1-800-955-8771)
    • Fax: 407-226-1901
    • Write:
      9102 Southpark Center Loop, Suite 200
      Orlando, FL 32819
      Attn: Grievance and Appeals
  • For Part D (Prescription Drug) Appeals:
    • Call: 1-877-980-8764 (TTY/TDD: 1-800-498-5428)
    • Fax: 1-877-239-4565
    • Write:
      Partners Rx
      Part D Appeals Coordinator
      Mail Stop CA 106-0286
      3515 Harbor Blvd.
      Costa Mesa, CA 92626

For the details of making an appeal, including Part D appeals, click the link below.king an appeal, including Part D appeals, click the link below.

You can also get the Appointment of Representative form on the CMS website.

If upon appeal, we uphold our original decision, in whole or part, you may request an independent review entity (IRE) to make an independent decision. The IRE has a contract with CMS to review these Member appeals. They will make a decision and notify you and us of their decision. If the IRE upholds PUP's decision, you will be informed of further rights to administrative and judicial review.

Requesting a Grievance Report

When you ask for it, the government requires PUP to provide you with reports that describe what happened to formal complaints that we received.

There are two types of formal complaints: Appeals and Grievances. Medicare members have a right to file an appeal or grievance with their Medicare health plans. An appeal is a formal complaint about Physicians United Plan’s decision not to pay for, not to provide, or to stop an item or service that a Medicare member believes s/he needs.

Each Medicare health plan will have different numbers of appeals and quality of care grievances, and these numbers can mean different things. For example, a Medicare health plan might have a small number of appeals and quality of care grievances because the plan talks with members about their concerns and agrees to find solutions. You may contact the plan and ask for a summary report of the number of grievances and appeals received and what happened to those complaints over a specific period of time.