Your health and satisfaction are important to us. When you have a problem or concern, please first call RiverSpring MAP (D-SNP) at 1-800-362-2266 (TTY/TDD: 711). Our member service staff will work with you to try and find a satisfactory solution to your problem.

You can also contact us to ask about the grievance and appeal process, or the status on the processing of your grievance or appeal, or for information on the total number of grievances, appeals and exceptions filed with RiverSpring MAP (D-SNP).

For more information, please see the Member Handbook and Evidence of Coverage.

Organization Determinations

An organization determination is when you ask RiverSpring MAP (D-SNP) to make a coverage decision that involves your medical care. An organization determination is the Plan’s initial decision about whether we will provide the medical care or service a member requests, or pay for a service a member has received. You, your doctor, or your representative can request an organization determination.

Grievances

A grievance is a complaint or concern that you have about your covered services or care. This includes any concerns about the quality of your care, our network providers or network pharmacies.

If you wish to file a grievance directly with Medicare, please follow the instructions on the Medicare Complaint Form.

Appeals

An appeal is a way for you to challenge a coverage decision if you think it is wrong. You can ask RiverSpring MAP (D-SNP) to reconsider a coverage decision by filing an appeal.

How to Request a Coverage Decision or File an Appeal or Complaint:

To request a coverage decision or file an appeal or complaint about your medical care, you may call or write to us at:

RiverSpring MAP (D-SNP)
Attn: Appeals & Grievances
80 West 225th Street
Bronx, New York 10463

Phone: 1-800-362-2266 (TTY/TDD: 711), 7 days a week, 8 a.m. to 8 p.m. ET.

Fax: 1-888-341-5009

To request a coverage decision or file an appeal or complaint about Part D Prescription Drugs, you may call or write to us at:

Express Scripts
P.O. Box 66562
St. Louis, MO 63166
Phone: 1-844-685-6364 (TTY/TDD: 1-800-716-3231), 24 hours a day, 7 days a week.

Fax: 1-877-852-4070

For coverage determination, grievance and appeals process, please review Chapter 9 of your Evidence of Coverage. Chapter 9 explains the process that is available for you to choose from when you either have a problem with coverage of medical services or prescription drugs. Since you have Medicare and get assistance from Medicaid the information in chapter 9 applies to all of your Medicare and Medicaid benefits. You do not have to use one process for your Medicare benefits and a different process for your Medicaid benefits. This is sometimes called an “integrated process” because it integrates Medicare and Medicaid processes. If you would like help with a coverage determination, grievance or appeal process, contact Member Services at 1-800-362-2266 (TTY/TDD: 711), 7 days a week, 8 a.m. to 8 p.m. ET.

Appointment of Representative

If you wish to name a family member, friend or trusted person to act on your behalf with any request, grievance, coverage determination or appeal, you can appoint that person to act for you as your “representative.” To appoint a representative you must complete an Appointment of Representative (AOR) Form (Click on the link for English or Spanish), which must be signed by you and by the person you are appointing. A representative appointed by the court or in accordance with State law may also act on your behalf. Please note that the appointment will be valid for one year from the signature date unless you revoke it in writing.

You can give us a copy of the form or mail it to us:

RiverSpring Health Plans
Attn: Members Services Department
80 West 225th Street
Bronx, New York 10463

The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Plan members with free, confidential assistance on any services offered by RiverSpring MAP (D-SNP). ICAN may be reached toll free at 1-844-614-8800 or online at http://www.icannys.org.

Disenrollment

For more information about Plan and Member rights and responsibilities upon disenrollment, refer to Chapter 8 of the RiverSpring MAP (D-SNP) Evidence of Coverage.

Potential for Contract Termination

RiverSpring MAP (D-SNP) contracts with both the Centers for Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH) to provide Medicare and Medicaid benefits to our members. The RiverSpring MAP (D-SNP) contract with either CMS or NYSDOH may be terminated or not renewed, which will result in termination of your enrollment from RiverSpring MAP (D-SNP). If this happens, we will notify you in writing before your coverage ends, and explain your options for Medicare and Medicaid coverage.

Until your disenrollment is effective, you will keep getting your covered services and drugs through RiverSpring MAP (D-SNP). In addition:

• RiverSpring MAP (D-SNP) will work with Medicare and Medicaid to ensure an orderly transition.
• The benefits and rules described in your Evidence of Coverage and Member Handbook will continue until your membership ends.
• You can enroll in another MAP Plan to continue your coverage or return to original Medicare and Medicaid fee for service.

Please see your Member Handbook and Evidence of Coverage for details regarding termination of coverage and disenrollment provisions. For more information about Plan and Member rights and responsibilities upon disenrollment, refer to Chapter 8 of the Evidence of Coverage.