Whether your request is about benefits covered by Medicare or Medicaid, if you would like help deciding whether to use the Medicare process or the Medicaid process or both, please contact Member Services at 1-844-969-5366 (Toll-free) 711 (TTY) Monday-Sunday 8:00 am – 8:00 pm., October through March and Monday-Friday 8:00 am – 8:00 pm April through September
The type of request you are having:
- For some types of requests, you need to use the process for coverage decisions and appeals.
- For other types of requests, you need to use the process for making complaints.
These processes have been approved by Medicare. To ensure fairness and prompt handling of your requests, each process has a set of rules, procedures, and deadlines that must be followed by you and by us.
Asking for coverage decisions
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay.
You or your doctor can call Member Services 1-844-969-5366 (Toll-free) 711 (TTY), Monday-Sunday 8:00 am – 8:00 pm., October through March and Monday-Friday 8:00 am – 8:00 pm April through September or send to the plan a letter asking for a coverage decision if your doctor is unsure whether we will cover a particular medical service or prescription drug or refuses to provide the medical care you think that you need.
If you need to ask the Plan for a coverage decision on a prescription drug you are taking or will be taking, you can also submit a request online by clicking on the below link to access an online form.
Request for Medicare Prescription Drug Coverage Determination (Online Request)
Request for Medicare Prescription Drug Coverage Determination – (Mail Form)
Asking for an appeal
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
Appeals may be submitted orally or in writing to the plan. If you need further assistance with the appeals process, you may contact Member Services.
You can also submit a request online by clicking on the below link to access an online form.
Request for Redetermination of Medicare Prescription Drug Denial (Online Request)
Request for Redetermination of Medicare Prescription Drug Denial (Mail Form)
Filing a grievance
You can file a grievance by calling Member Services at 1-844-969-5366 (Toll-free)
711 (TTY) Monday-Sunday 8:00 am – 8:00 pm, October through March and Monday-Friday 8:00 am – 8:00 pm, April through September or you can send your grievance in writing to:
Leon Health, Inc.
Grievances and Appeals Department
P.O. Box 668230
Miami, FL 33166
How to obtain aggregate numbers of Grievances, Coverage Determinations, Appeals and Exceptions
As a Medicare Advantage Organization, Leon Health must disclose grievances, coverage determinations, appeals and exceptions data, upon request, to individuals eligible to elect a Medicare Advantage organization. By appeals data we mean all appeals filed with Leon Health that are accepted for review, or withdrawn upon the member’s requests, but excludes appeals that Leon Health forwards to CMS’ Independent Review Entity (IRE) for dismissal.
If you want to obtain an aggregate total of grievances, appeals, o exceptions filed with the plan, please call us at 1-844-964-5366.
Do you need to file a complaint?
If you need to file a complaint with Medicare, you may file your complaint online by submitting the Centers for Medicare and Medicaid Services (CMS) Medicare complaint form at www.medicare.gov. You may also do so by calling CMS at 1-800-Medicare (800-633-4227), available 24 hours a day, the seven days of the week.
