Members of our Medicare Advantage health plans have the right to request an organization determination including the right to file an appeal and the right to file a grievance. Medicare Advantage health plan organizations must identify, track, resolve and report all activity related to an appeal or grievance.

Please Note: For more detailed information, you can review the Evidence of Coverage booklet that Unison Advantage sends you when you become a member. You can also find the Evidence of Coverage by clicking on the “Back” button at the top left side of this page, then clicking on the “Evidence of Coverage” link on the page.

If you have any questions about this information, you can call Member Services at 1.800.290.4009 (TTY: 711), 8:00 a.m. – 8:00 p.m., seven days a week. From March 2 through Nov. 14, you may receive our messaging service on weekends and holidays.”  

Medicare Advantage Member Appeals

What is an Appeal?

An appeal is a type of request you make when you want us to reconsider a decision concerning coverage of a service or the amount your health plan pays or will pay for a service. The initial decision concerning medical care or services is called an "organization determination."

When can an Appeal be filed?

You may file an appeal within 60 calendar days of the date of the initial organization determination. The 60-day limit may be extended for good cause. Include in your written request the reason why you could not file within the 60-day timeframe.

Who can file an Appeal?

You may file an appeal or someone else may file an appeal on your behalf. You must appoint the individual to act as your representative to file the appeal for you. To learn how to name a representative, contact Member Services.

How can an Appeal be filed?

An appeal must be filed in writing directly to us. You may call Member Services for additional information at 1.800.290.4009 (TTY: 711), 8:00 a.m. – 8:00 p.m., seven days a week. From March 2 through Nov. 14, you may receive our messaging service on weekends and holidays.

Fast Reviews

You have the right to request and receive fast decisions affecting your medical treatment in "time-sensitive" situations. A situation is time-sensitive if waiting for a decision to be made within the standard timeframe could seriously harm your health or your ability to function. If your doctor provides a written or oral statement supporting your need of a fast review we will automatically give you a fast review. A decision will be issued as quickly as possible, but no later than 72 hours after receiving the request.

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Medicare Advantage Member Grievances

What is a Grievance?

A grievance is a complaint that doesn't involve coverage for an item or service by your health plan or a contracting medical provider. If your grievance involves quality of care, you have the right to file a grievance with the Quality Improvement Organization (QIO) of your state.

• The QIO in Pennsylvania is Quality Insights of Pennsylvania, 1.877.346.6180 (TTY: 711), 2601 Market Place St., Suite 320, Harrisburg, PA 17110
• The QIO in Ohio is kePRO,1.800.589.7337 (TTY: 711), Rock Run Center, 5700 Lombardo Center Drive, Suite 100, Steven Hills, OH 44131
• The QIO in Tennessee is Qsource, 1.800.528.2655 (TTY: 711), 3175 Lenox Park Blvd., Suite 309, Memphis, TN 38115

When can a Grievance be filed?

You may file a grievance within 60 calendar days of the date of the event causing the grievance. The 60-day limit may be extended for good cause. Include in your written request the reason why you could not file within the 60-day timeframe. There is no time limit for complaints concerning quality of care.

Who can file a Grievance?

You may file a grievance or someone else may file a grievance on your behalf. You must appoint the individual to act as your representative to file the grievance for you. To learn how to name a representative, contact Member Services at 1.800.290.4009 (TTY: 711), 8:00 a.m. – 8:00 p.m., seven days a week. From March 2 through Nov. 14, you may receive our messaging service on weekends and holidays.”  

How can a Grievance be filed?

A grievance may be filed in writing or verbally by contacting Member Services at 1.800.290.4009 (TTY: 711), 8:00 a.m. – 8:00 p.m., seven days a week. From March 2 through Nov. 14, you may receive our messaging service on weekends and holidays.  Member Services can also be reached at: Unison Advantage, Attn: Member Services, 1001 Brinton Road, Pittsburgh, PA 15221.

Fast Grievances

You have the right to file a fast grievance. We will respond to fast grievances within 24 hours of receipt. You may file a fast grievance if you disagree with our decision to deny your request for a fast review. You may also file a fast grievance if we notify you that we are extending our timeframe to make an organization determination or reconsideration decision.

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For Members with Medicare Part D Drug Coverage through our Plan

Coverage Determinations

We will make an initial decision as to whether or not we will provide the Part D drug you are requesting or pay for the Part D drug you already received. This initial decision is called a "coverage determination."

Exceptions

You or your doctor may ask us to make an exception to our Part D coverage determination. You may request an exception if you believe you need a drug that is not on our list of covered drugs. Generally, we will only approve your request for an exception if the alternative Part D drug is included in your plan's formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Your doctor or other prescriber must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor or other prescriber should be sent to us with the exception request. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy.

Part D Drug Appeals

If you are getting Medicare prescription Part D drug coverage through our plan you have the right to file an appeal.  This includes the right to appeal our decision regarding your exception request. Follow the process outlined above to file an appeal. An appeal concerning coverage determinations must be filed in writing directly to us.

Part D Drug Grievance

If you are getting Medicare prescription Part D drug coverage through our plan you have the right to file a grievance. Follow the process outlined above to file a Part D prescription drug grievance.

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