Appeals & Grievances
-
Toggle spoiler Part C (Medical Services) & Part D (Prescription Drug) Grievances
Grievance
A grievance is any dispute (other than one involving a coverage determination or an organization determination) that expresses dissatisfaction with the operations, activities, or behavior of Eon Health or one of our providers. A grievance may be filed by phone or in writing or fax and must be field no later than sixty calendar days after the event or incident.
Examples of a grievance:
- Unresolved issues with member services
- Problems with one of our network providers
- Problem with waiting times at your physician’s office
- Suspicion of fraud or abuse
- Marketing or sales activities you feel are inappropriate
-
Toggle spoiler How to File a Grievance
- Call us at:
1-888-906-3889 (TTY: 711)
From October 1 – March 31, seven days a week, from 8am – 8pm and April 1 – September 30, Monday through Friday, from 8am – 8pm (you may leave a voicemail Saturday, Sunday and Holidays)
- Mail your complaint to:
To mail in a grievance, you may use the Member Grievance Form
Please send your grievance to this address:
Eon Health
Attn: Member Services
3601 S.W. 160th Avenue, Suite 450
Miramar, FL 33027- Send a fax to:
1-866-235-5181
When your complaint is about quality of care, you can make your complaint to the Quality Improvement Organization (QIO).
You can also submit feedback directly to Medicare by using the form below. You can also call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.
-
Toggle spoiler Prior Authorization Requests
Some of our services may require prior authorization. This means your doctor must ask us if we will cover the procedure or service. Your doctor may also be required to provide us documentation showing that it is medically necessary for you to receive these services.
-
Toggle spoiler Data Requests
Eon Health tracks and maintains records about the receipt and handling of grievances, appeals, and exceptions. We will also disclose grievances, appeals, and exceptions data to you upon request. Eon Health can also provide an aggregate number of grievances, appeals, and exceptions filed with our plans. To obtain this data, please call Eon Health at the following toll-free number:
1-888-906-3889 (TTY: 711)
From October 1 – March 31, seven days a week, from 8am – 8pm and April 1 – September 30, Monday through Friday, from 8am – 8pm (you may leave a voicemail Saturday, Sunday and Holidays)
-
Toggle spoiler Appointed Representatives
Members may name a relative, friend, advocate, or someone else to act on his or her behalf. This process is called Appointing a Representative. Other persons may already be authorized under state law to act on a member’s behalf. In order to appoint another individual to act on a member’s behalf, both the member and the designated individual must sign and date a statement that gives this person legal permission to act as an Appointed Representative.
To appoint a representative, you may use this form: Appointment of Representative Form
After completing the form, please mail it to the following address:
Eon Health
Attn: Member Services
3601 S.W. 160th Avenue, Suite 450
Miramar, FL 33027 -
Toggle spoiler Status of a Request
For questions regarding the process or status of a coverage determination, grievance, organization determination, redetermination, or reconsideration request, you or your appointed representative should call Eon Health at the following toll-free number:
1-888-906-3889 (TTY: 711)
From October 1 – March 31, seven days a week, from 8am – 8pm and April 1 – September 30, Monday through Friday, from 8am – 8pm (you may leave a voicemail Saturday, Sunday and Holidays). Calls to this number are free.
-
Toggle spoiler Organization Determination and Part C (Medical Services) Appeals
An organization determination is a decision we make about your benefits and coverage or about what we will pay for Medical Services.
If Eon Health denies all or part of a request for a service or payment of a service, you can ask for an appeal. A request for an appeal may be made by phone or in writing and typically must be filed within sixty calendar days from the date of the notice of the denial (organization determination). More time may be granted depending on circumstances. When you make an appeal, Eon Health will review your unfavorable organization determination. The first level of the appeal process for medical services (Part C) is called Reconsideration.
There are five levels of appeals. If the Reconsideration decision is not entirely in the member’s favor, Eon Health will forward the case to an Independent Review Entity (IRE). There are other levels of appeal that may be available after the IRE review.
-
Toggle spoiler How to Request a Part C (Medical Services) Appeal
As an Eon Health member, you, your appointed representative, or your prescribing physician may file for an appeal.
You may use the following form to request a medical (Part C) appeal:
Medical (Part C) Appeal Request Form
- You can call us at:
1-888-906-3889 (TTY: 711)
From October 1 – March 31, seven days a week, from 8am – 8pm and April 1 – September 30, Monday through Friday, from 8am – 8pm (you may leave a voicemail Saturday, Sunday and Holidays). Calls to this number are free.
- Send a fax to:
1-866-235-5181
- Mail your request to:
Eon Health
Attn: Member Services
3601 S.W. 160th Avenue, Suite 450
Miramar, FL 33027 -
Toggle spoiler Part D (Prescription Drug) Appeals
If you are unsatisfied with the outcome of a coverage determination request, you can ask for an appeal. An appeal may be made by phone or in writing and the request must be filed within sixty calendar days from the date of the notice of denial (Coverage Determination). More time may be granted depending on circumstances. When you make an appeal, Eon Health will review your unfavorable coverage determination. The first level of the appeal process for prescription drug (Part D) is called Redetermination.
There are five levels of appeals. If the Redetermination decision is not entirely in the member’s favor, you will be notified in writing and you may request a review by the Independent Review Entity (IRE). There are other levels of appeal that may be available after the IRE review.
-
Toggle spoiler How to request a Part D (Prescription Drug) Appeal
As an Eon Health member, you, your appointed representative, or your prescribing physician may file for an appeal of a coverage determination.
To file a redetermination, you may use the Redetermination Request Form
- You can call us at:
1-888-906-3889 (TTY: 711)
From October 1 – March 31, seven days a week, from 8am – 8pm and April 1 – September 30, Monday through Friday, from 8am – 8pm (you may leave a voicemail Saturday, Sunday and Holidays). Calls to this number are free.
- Send a fax to:
1-866-235-5181
- Mail your request to:
OptumRx
Attn: Member Services
3601 S.W. 160th Avenue, Suite 450
Miramar, FL 33027 -
Toggle spoiler Data Requests
Eon Health tracks and maintains records about the receipt and handling of grievances, appeals, and exceptions. We will also disclose grievances, appeals, and exceptions data to you upon request. Eon Health can also provide an aggregate number of grievances, appeals, and exceptions filed with our plans. To obtain this data, please call Eon Health at the following toll-free number:
1-888-906-3889 (TTY: 711)
From October 1 – March 31, seven days a week, from 8am – 8pm and April 1 – September 30, Monday through Friday, from 8am – 8pm (you may leave a voicemail Saturday, Sunday and Holidays)
-
Toggle spoiler Appointed Representatives
Members may name a relative, friend, advocate, or someone else to act on his or her behalf. This process is called Appointing a Representative. Other persons may already be authorized under state law to act on a member’s behalf. In order to appoint another individual to act on a member’s behalf, both the member and the designated individual must sign and date a statement that gives this person legal permission to act as an Appointed Representative.
To appoint a representative, you may use this form: Appointment of Representative Form
After completing the form, please mail it to the following address:
Eon Health
Attn: Member Services
3601 S.W. 160th Avenue, Suite 450
Miramar, FL 33027 -
Toggle spoiler Status of a Request
For questions regarding the process or status of a coverage determination, grievance, organization determination, redetermination, or reconsideration request, you or your appointed representative should call Eon Health at the following toll-free number:
1-888-906-3889 (TTY: 711)
From October 1 – March 31, seven days a week, from 8am – 8pm and April 1 – September 30, Monday through Friday, from 8am – 8pm (you may leave a voicemail Saturday, Sunday and Holidays). Calls to this number are free.
-
Toggle spoiler Waiver of Liability
In accordance with the CMS Managed Care Manual, Chapter 13, Section 60.1.1, Non-Contract Providers are, "permitted to file a standard appeal for a denied claim only if the non-contract provider completes a waiver of liability statement, which providers that the non-contract provider will not bill the enrollee regardless of the outcome of the appeal".
If Eon Helth does not receive this required documentation by the end of the post-service appeal time frame (60 calendar days, plus an additional 14 days extension), the case will be dismissed, as per CMS guidance.
