Coverage Decision, Appeal or Grievance

Organization Determinations, Appeals and Grievances

Need to file an Appeal, Grievance, or Complaint regarding any service or other concern? Let us guide you.

• Organization Determination – A decision made by FirstMedicare Direct about whether a medical service or item requested for you is covered by the plan and the amount, if any, you are required to pay for the item or service.
• Appeal – A formal request filed with the plan if you disagree with our decision and want to ask us to review and change a coverage decision we have made. (Must be filed no later than 60 calendar days from the date on written decision notice.)
• Grievance – Any complaint or dispute expressing dissatisfaction with the manner in which FirstMedicare Director or a delegated entity provides health care services, (must be filed no later than 60 calendar days from the date of the event.)

How do I file a grievance?

To file or check the status of a grievance or an appeal, the first step is to call Member Services. Member Services can also assist members with requests to obtain an aggregate number of grievances, appeals, and exceptions filed with the Plan/Part D sponsor.

Member Services

(877) 210-9167 (TTY 711)

Daily 8 a.m. to 5 p.m. local time, closed from noon to 1 p.m.

Voicemail used on holidays and weekends, April 1 – September 30.

File by mail

If you do not wish to call or you called and were not satisfied, you can put your complaint in writing and send it to the address or fax below. Be sure to describe your complaint.

FirstCarolinaCare Insurance Company
Attention: Appeals Department
3310 Fields South Dr.
Champaign, IL 61822
Fax: (217) 902-9708

FirstCarolinaCare Insurance Company
Attention: Grievance Department
3310 Fields South Dr.
Champaign, IL 61822

The following document contains detailed information if you wish to appoint a representative to file the complaint on your behalf.

Appointing a Representative

What if I don’t want to file my complaint through FirstCarolinaCare Insurance Company?

You can also go directly through Medicare.gov or call (800) MEDICARE to file a complaint.

You can also get help with Medicare-related complaints, grievances, and information requests from Medicare’s Ombudsman. 

How do I request a coverage determination or medical exception for a drug?

You, your authorized representative, or your prescribing doctor can use our Prior Authorization Request Form, Coverage Determination Request Form, or Redetermination Request Form to ask for a coverage determination. Send any additional chart notes in one of the following ways:

Mail

FirstCarolinaCare Insurance Company
Attention: Pharmacy Department or Medical Management
3310 Fields South Dr.
Champaign, IL 61822

Email

MemberServices@FirstCarolinaCare.com

Fax

(217) 902-9798