Member Resources provides you with the tools, information and resources to help you get the most out of your Simpra Advantage (PPO I-SNP) or Simpra Advantage (PPO D-SNP) benefits and coverage and much more.
- To request a hardcopy of the Simpra Advantage provider directory or the Evidence of Coverage, please call Member Services at 1-844-637-4770 (TTY 711).
- To learn about your members rights and responsibilities, please see Chapter 8 of your:
Simpra Advantage is a PPO and does not restrict access to providers. You may see any doctor or specialist you choose who accepts Medicare beneficiaries.
What is an Organization Determination?
An organization determination is any determination (i.e. approval or denial) made by a Medicare health plan (e.g., Simpra Advantage) regarding:
- Receipt of, or payment for, a managed care item or service;
- The amount a health plan requires an enrollee to pay for an item or service; or
- A limit on the quantity of items or services.
You may file a standard reconsideration if you disagree with the decision that was made by the Simpra Advantage.
Who Can Request an Organization Determination?
An enrollee, an enrollee’s representative, or any provider that furnishes, or intends to furnish, services to an enrollee, may request a standard organization determination by filing an oral or written request with the Simpra Advantage. Expedited requests may be requested by an enrollee, an enrollee’s representative, or any physician, regardless of whether the physician is affiliated with Simpra Advantage.
When Can an Organization Determination Be Requested?
An organization determination made by Simpra Advantage can be requested with respect to any of the following:
- Payment for temporarily out of the area renal dialysis services, emergency services, post-stabilization care, or urgently needed services;
- Payment for any other health services furnished by a provider other than Simpra Advantage that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the Simpra Advantage;
- Simpra Advantage’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by Simpra Advantage;
- Reduction, or premature discontinuation of a previously authorized ongoing course of treatment; or
- Failure of Simpra Advantage to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee.
Where Can an Organization Determination be filed?
The way you submit an organization redetermination depends on when your service is happening. If you are requesting an organization redetermination:
Before the service is performed: This is considered an authorization request, please contact our UM dept at 1-844-637-4770 (TTY 711), option 3
After a service is provided: This is considered a claim so you should follow the procedures above for submitting a claim.
Our plan has fourteen (14) calendar days (for a standard organization determination request) or seventy-two (72) hours (for an expedited request) from the date it gets your request to notify you of its decision.
What Is a Standard Reconsideration (i.e., Appeal)?
A reconsideration is also known as an appeal. If Simpra Advantage denies an enrollee’s request for an item, service in whole or in part, or any amounts the enrollee must pay for a service (issues an adverse organization determination), the enrollee may appeal the decision to the plan by requesting a reconsideration.
A reconsideration consists of a review of an adverse organization determination or termination of services decision, the evidence and findings upon which it was based, and any other evidence that the parties submit or that is obtained by the health plan, the QIO, or the independent review entity.
Who can Request a Standard Reconsideration (i.e., Appeal)?
- An enrollee or an enrollee’s appointed or authorized representative may request a standard or expedited reconsideration (i.e., appeal).
- A non-contract physician or provider to a Medicare Health plan may request a standard reconsideration without being appointed as the enrollee’s representative, on the enrollee’s behalf.
- Non-contract providers must include a signed Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal.
- A physician regardless of whether the physician is affiliated with the plan may request that a Medicare Health Plan expedite a reconsideration.
- Contract providers do not have appeal rights.
How to Request a Reconsideration
- Reconsideration requests must be filed with the health plan within 60 calendar days from the date of the notice of the organization determination.
- Expedited requests can be made either orally or in writing.
- Standard requests must be made in writing unless the enrollee’s plan accepts oral requests. An enrollee should call the plan or check his or her Evidence of Coverage to determine if the plan accepts oral standard requests.
Important Things to Know About Asking for Standard Reconsideration:
A party must file the request for reconsideration within sixty (60) calendar days from the date of the notice of the organization determination. If a request for reconsideration is filed beyond the sixty (60) calendar day time frame and good cause for late filing is not provided, Simpra Advantage will forward the request to the independent review entity for dismissal.
Once the plan receives the request, it must make its decision and notify the enrollee of its decision as quickly as the enrollee’s health requires, but no later than 72 hours for expedited requests or 30 calendar days for standard requests, or 60 calendar days for payment requests.
Our plan can accept or deny your request. If we approve your request for a standard reconsideration, our approval is valid until the end of the plan year.
Where Can a Reconsideration Be Filed?
You or your representative can request a reconsideration by writing directly to us at:
- Simpra Advantage – Appeals and Grievances
Department, PO Box 2190 Glen Allen, VA 23058-2190
- Fax: 1-800-862-2730 (TTY 711)
- Email: email@example.com
What is a Good Cause Exception?
If a party shows good cause, Simpra Advantage may extend the time frame for filing a request for reconsideration (i.e., appeal). Simpra Advantage will consider the circumstance that kept the enrollee or representative from making the request on time and whether any organizational actions might have misled the enrollee.
Examples of circumstances where good cause may exist to file a late appeal include (but are not limited to) the following situations:
- The enrollee did not personally receive the adverse organization determination notice, or he/she received it late;
- The enrollee was seriously ill, which prevented a timely appeal;
- There was a death or serious illness in the enrollee’s immediate family;
- An accident caused important records to be destroyed;
- Documentation was difficult to locate within the time limits;
- The enrollee had incorrect or incomplete information concerning the reconsideration process; or
- The enrollee lacked capacity to understand the time frame for filing a request for reconsideration.
What is an Appeal?
An appeal is a formal request by the member (or his/her authorized representative) to change a decision previously made by Simpra Advantage.
For example, you may file an appeal for any of the following reasons:
- Simpra Advantage refuses to cover or pay for services you think Simpra Advantage should cover.
- Simpra Advantage or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
- Simpra Advantage or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
- If you think that Simpra Advantage is stopping your coverage too soon.
Who Can File an Appeal?
You or your authorized representative may file an appeal. You may also have your physician file an appeal on your behalf.
You may appoint an individual to act as your representative to file the grievance or an appeal for you by following the steps below.
Provide our health plan with:
- Your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: “I [your name] appoint [name of representative] to act as my representative in requesting an appeal from Simpra Advantage and/or CMS regarding the denial or discontinuation of medical services.”
- Your name, address and phone number and that of your representative, if applicable.
- A signed and dated statement by you and the person you are appointing as representative.
- You must include this signed statement with your appeal.
- Reasons for appealing, and any evidence you wish to attach.
- Supporting medical records, doctors’ letters, or other information that explains why your plan should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.
When Can an Appeal Be Filed?
You may file an appeal within sixty (60) calendar days of the date of the notice of the initial organization determination.
Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day time frame.
Can I Expedite an Appeal?
Yes, you may file an expedited grievance by calling: 1-844-637-4770 (TTY 711), option 6.
You have the right to request and receive expedited decisions affecting your medical treatment in “time-sensitive” situations. This will be considered a fast appeal.
A “time-sensitive” situation is a situation where waiting for a decision to be made within the time frame of the standard decision-making process could seriously jeopardize 1) your life or health, or 2) your ability to regain maximum function.
If Simpra Advantage decides, based on medical criteria, that your situation is “time-sensitive” or if any physician calls or writes in support of your request for an expedited review, Simpra Advantage or your Primary Care Physician will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request.
Where Can an Appeal Be Filed?
You may file a standard or fast appeal to: Simpra Advantage, Appeals and Grievances Department, PO Box 2190 Glen Allen, VA 23058, Phone 1-844-637-4770 (TTY 711), Fax 1-800-862-2730
What Happens Next?
We will review your appeal. If any of the services you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by a reviewer outside of Simpra Advantage. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.
What Is a Grievance?
A grievance is a type of complaint that does not involve payment or denial of services by Simpra Advantage or a Contracting Medical Provider. For example, you would file a grievance if:
- You have a problem with things such as the quality of your care during a hospital stay;
- You feel you are being encouraged to leave your plan;
- Waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room;
- Waiting too long for prescriptions to be filled;
- The way your doctors, network pharmacists or others behave;
- Not being able to reach someone by phone or obtain the information you need; or
- Lack of cleanliness or the condition of the office.
Who Can File a Grievance?
A grievance may be filed by any of the following:
- You may file a grievance.
- Your authorized representative.
Why File a Grievance?
You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with Simpra Advantage or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding, or lack of information.
Can I Expedite a Grievance?
Yes, you may file an expedited grievance by calling: 1-844-637-4770 (TTY 711), option 6. If you disagree with Simpra Advantage’s decision to extend the timeframe on your organization determination or reconsideration, or Simpra Advantage’s decision to process your expedited request as a standard request. In such cases, you may file an expedited grievance and receive a response within twenty-four (24) hours of receipt.
Where can a Grievance Be Filed?
You may file a standard grievance in writing directly to: Simpra Advantage -Appeals and Grievances Department, PO Box 2190 Glen Allen, VA 23058-2190 or by faxing 1-800-862-2730 or over the phone by contacting our Member Services Department at our toll-free number at 1-844-637-4770 (TTY 711).
If you would like you can file a complaint directly to Medicare by filling out the complaint form at https://www.medicare.gov/MedicareComplaintForm/home.aspx.
You have the right to request the number of appeals and the number of quality of care grievances received by Simpra Advantage during a plan year.
Please call Member Services at 1-844-637-4770 (TTY 711), Fax 1-800-862-2730.
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.
To appoint a representative, fill out the CMS Appointment of Representative Form (CMS Form-1696). Once you have filled out the form, you may print and mail the form to:
PO Box 2190
Glen Allen, VA 23058
You may also send a fax to 1-800-862-2730
A description of, and information on how to appoint a representative, you may also call Member Services for Simpra Advantage at 1-844-637-4770 (TTY 711).
Ending your Membership in Simpra Advantage 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 written 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 Simpra Advantage, you can do any of the following:
- See your Evidence of Coverage for more information and to learn about the rights, benefits, and responsibilities of Members.
- 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 (www.medicare.gov). Or, you can order a printed copy by calling Medicare at the number below.
- Contact 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.
- Annual Notice of Change (ANOC)
- Evidence of Coverage (EOC)
- Summary of Benefits
- LIS Premium Summary
- Services that Require Prior Authorization
- Annual Notice of Change (ANOC)
- Evidence of Coverage (EOC)
- Summary of Benefits
- LIS Premium Summary
- Services that Require Prior Authorization
For more information, please call us at:
1-844-637-4770 (TTY 711)