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Medicaid Member Grievances and Appeals

Grievances

Virginia Premier and its providers are dedicated to your health and well-being, and we are available to assist you with any questions or concerns. If you have a problem that has not been resolved, let us know. Your questions and grievances are important to us. Virginia Premier will make every effort to solve the issue satisfactorily. A Member Services Representative can assist you with your concerns about the following: 

  • Difficulty scheduling a doctor’s appointment
  • Your treatment as a Virginia Premier Member
  • Your medical care or treatment
  • Payment of medical bills
  • Medicaid Fraud and Abuse
  • Disagreement with our decision to not approve care

Types of Grievances

  • Grievance
    An expression of dissatisfaction about any matter other than an “action.” Possible subjects for grievances include:
    • Benefits
    • Staff or provider’s failure to respect your rights
    • Payment and reimbursement issues
    • Administrative issues
    • Services provided
  • Quality of Care Grievance
    A quality of care grievance is an expression of dissatisfaction regarding the quality of medical treatment rendered by a provider.
  • Quality of Service Grievance
    A quality of service grievance is an expression of dissatisfaction regarding how the member feels he/she was treated as a person. This also includes dissatisfaction related to lack of access to care.

Submitting a Grievance

Virginia Premier will respond to your grievance within thirty (30) days of the date of the initial receipt or sooner if the condition warrants a quicker response. Grievances may be extended up to fourteen (14) calendar days if the member requests such extension or if the health plan shows (to the satisfaction of the State agency, DMAS, upon its request) that additional information is needed and that the delay best serves the member. The written notice must be mailed to the member no later than the 14th day and must describe the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he/she disagrees with that decision. The review will be completed for final determination as expeditiously as the member’s health condition allows and shall not exceed the date on which the extension expires.

If you do not agree with the decision made by Virginia Premier, call Virginia Premier’s Medical Management Division (toll-free) at 855-813-0349 (TTY: 800-828-1120; TDD: 800-828-1140) or write us at the address listed below:

Virginia Premier
Attn: Grievance & Appeals
P.O. Box 5244
Richmond, VA 23220
Fax Number: 877-307-1649

Appeals

If you are not happy with the answer given to you by Virginia Premier concerning your grievance or other action, you or another person (i.e., practitioner/provider, legal representative, etc.) authorized by you can file an appeal within thirty (30) days of receiving Virginia Premier’s response. The member’s benefits will automatically continue, without any action from the member, throughout the appeal process including the period during which and when the State Fair Hearing is pending if all of the following criteria are met:

  • The member or the practitioner/provider, on behalf of the member, files the appeal within ten (10) days of the date on which Virginia Premier mailed the notice of adverse action or prior to the effective date of Virginia Premier’s notice of adverse action; and
  • The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; and
  • The services were ordered by an authorized provider; and
  • The original period covered by the initial authorization has not expired; and
  • The member requests extension of benefits.

Submitting an Appeal

To file an appeal or request assistance with filing an appeal, contact Virginia Premier’s Medical Management (toll-free) at 855-813-0349. (TTY: 800-828-1120; TDD: 800-828-1140).

When filing a request for an appeal, please be sure to always include the following information in, or with your cover letter:

  • The denial decision you are appealing
  • Your Complete Mailing Address
  • Your Medicaid I.D. Number
  • Your Name
  • Reference/Referral Number (if applicable)
  • A copy of the denial letter that prompted your decision to appeal
  • All supporting documentation that you feel will help to reverse Virginia Premier’s decision
  • Your Phone Number (including area code)

When filing a request for an appeal, please use the correct address for the type of appeal you are filing (see below). Sending your appeal request to the appropriate address, along with the information listed above, will expedite processing.

Types of Appeals

  • Clinical Appeals
      • Lack of Medical Necessity

    Mailing Address for Clinical Appeals:
    Virginia Premier
    Attn: Grievances & Appeals
    P.O. Box 5244
    Richmond, VA 23220
    Fax Number: 877-307-1649

Appeal Rights

You or your authorized representative may also submit a request for an expedited or standard State fair hearing directly to the Department of Medical Assistance Services (DMAS). FAMIS and Medallion 4.0 Members may submit a request for a State Fair Hearing to DMAS after exhausting the Virginia Premier appeals process. State fair hearing requests must be submitted to DMAS in writing. You or your authorized representative may write a letter or complete an Appeal Request Form. Forms are available on the Internet at www.dmas.virginia.gov, the local Department of Social Services, or by calling 804-371-8488.

Written requests to DMAS must be sent within 30 days of the date of the appeal response to:

Department of Medical Assistance Services
Appeals Division
600 East Broad Street
Richmond, Virginia 23219
804-371-8488

Virginia Premier offers two types of Appeals

  • Expedited Appeal
    An Expedited Appeal may be requested over the telephone when your provider determines that the standard appeals timeframe could jeopardize your life or health, ability to attain, maintain or regain maximum function. Telephone or fax the request to the numbers listed above. A written appeal is not necessary for expedited appeals. Once the request is received, Virginia Premier and/or DMAS will select an appeal physician of the same or similar specialty as typically manages the condition, procedure or treatment in question, who was not involved in the initial denial of services. Decisions for expedited appeals will take no more than 72 hours from the initial receipt of the appeal.
  • Standard Appeal
    Standard Appeals are generally made after the services have been rendered or completed and may be requested by phone or in writing. All verbal appeal requests must be followed by a written appeal request. You may obtain a copy of the appeals form by calling Member Services at 800-727-7536 and requesting one. You or your representative may request an in person interview to present additional evidence and allegations of fact or law within five (5) days of filing an appeal. All appeals will be resolved within 30 days. You may also address complaints or concerns about suspected Medicaid fraud or abuse in Virginia to:State Corporation Commission Bureau of Insurance
    P.O. Box 1157
    Richmond, Virginia 23218
    Toll-Free: 800-552-7945
    Local: 804-371-9741

    Virginia Department of Health Professions Perimeter Center
    9960 Mayland Drive, Suite 300
    Richmond, Virginia 23233
    Toll-Free: 800-533-1560
    Local: 804-367-4400
    Fax: 804-527-4475

    Virginia Department of Health Center for Quality Health Care Services and Consumer Protection
    Complaint Division
    3600 West Broad Street – Suite 216
    Richmond, Virginia 23230
    Toll-Free: 800-955-1819
    Fax: 804-367-2149

    Virginia Premier
    Medical Management
    Attn: Grievances & Appeals
    P.O. Box 5244
    Richmond, Virginia 23220

    Virginia Premier’s toll-free, anonymous, 24 hours Compliance Help Line: 800-620-1438

    All claims or grievances of any nature against Virginia Premier’s employees, agents, board members or officers, whether filed by a member or a spouse or personal representative of a member, should go through the Grievance and Appeals Procedures discussed above before any action or proceeding may be sought out.

    Virginia Premier’s policy is to respond promptly to inquiries, grievances and appeals through all stages of the process. For a copy of Virginia Premier’s complete policy and process, call Virginia Premier’s Member Services at 800-727-7536.

    For questions regarding your Medicaid eligibility, call your local DSS office.

    Virginia Premier Health Plan, Inc., is subject to regulations in this Commonwealth by the State Corporation Commission Bureau of Insurance pursuant to Title 38.2 and by the Virginia Department of Health pursuant to Title 32.1.

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