Complaints, Coverage Decisions, and Appeals
As a member of an Sentara Medicare plan, we want to work with you to resolve any problems or concerns you have about our health plan, your coverage for medical services or prescription drugs, your experiences at your doctor’s office, pharmacy, hospital, or other facility, and/or the quality of the care you receive.
Important information is included here to help you with issues you may experience. You cannot be disenrolled from an Sentara Medicare plan or penalized in any way if you file a complaint, request a coverage decision or file an appeal.
The following information applies to Sentara Medicare Value (HMO), Sentara Medicare Prime (HMO), Sentara Medicare Savings (HMO), and Sentara Medicare Salute (HMO).
Complaints, Coverage Decisions, and Appeals Processes for Medicare Part C and D document
More information about complaints, coverage decisions, and appeals can be found in your Evidence of Coverage (EOC). To view your EOC, please submit your ZIP code and navigate to your plan information.
In your EOC, Medicare uses different terms to describe complaints, coverage decisions, and appeals. These terms are explained below:
- Grievance
- A complaint.
- Organization Determination
- A coverage decision about a Part C medical service or item.
- Coverage Determination
- A coverage decision about a Part D prescription drug.
- Reconsideration
- First level appeal of an organization determination/coverage decision for a Part C medical service or item.
- Redetermination
- First level appeal of a coverage determination/coverage decision for a Part D prescription drug.
Appoint a Representative
You can have someone help you file a complaint, request a coverage decision, or file an appeal. If you do not have someone with durable power of attorney, is your court appointed guardian or healthcare proxy, you can appoint a representative such as a relative, friend, advocate, or attorney. To appoint a representative, complete the Medicare form below or write a letter with all of the same information that is in this form.
Appointment of Representative form on CMS.gov
Send the form or letter and legal documents (power of attorney or for your court-appointed guardian or health care proxy) to us with the completed form for the correct process below (see sections on complaints, coverage decisions, and appeal).
The doctor that is treating you can file a complaint, request a coverage decision, or file an appeal on your behalf without having to be appointed as your representative.
File a Complaint
You can file a complaint with Sentara Medicare or directly with Medicare. To learn more about filing a complaint, contact Sentara Medicare Member Services 1-800-927-6048 (TTY: 711), October 1 through March 31, 7 days a week, from 8 a.m. to 8 p.m. or April 1 through September 30, Monday through Friday, from 8 a.m. to 8 p.m.
How to file a complaint with Medicare at Medicare.gov
Form to use to file a complaint about Sentara Medicare at Medicare.gov
Request a Coverage Decision
You can ask if we will cover or pay for Part C medical services or items or Part D prescription drugs. To learn more about requesting a coverage or payment decision, read about it in the Complaints, Coverage Decisions and Appeals Processes for Medicare Part C and D document.
Sentara Medicare Plans Request for Drug Coverage Determination
Request a Standard decision for Medicare Part D (prescription drugs) electronically
File an Appeal about a Coverage Decision
You can file an appeal if we deny coverage or payment for Part C medical services or items or Part D prescription drugs. Follow the directions in the letter we sent to you that explains why we denied coverage or payment for services, items, or drugs.
File an appeal about a coverage decision for Part C medical services or items
Request for Medicare Prescription Drug Coverage Redetermination
Appeal information on Medicare.gov
For information about the number of appeals, grievances, and exceptions filed with Sentara Medicare, please use the contact information below:
Sentara Medicare
Appeals and Grievances Department
PO Box 62876
Virginia Beach, VA 23466
- Phone
- +1 (800) 927-6048
- TTY VA Relay Service
- +1 (800) 828-1140 or 711
If you are a member of Sentara Community Complete (HMO D-SNP) and Sentara Community Complete Select (HMO D-SNP) you have a concern about your health plan, the quality of your care or your coverage for certain services, you may follow an established process to resolve your concern. You cannot be disenrolled from our plan or penalized in any way if you make a complaint, request a coverage decision, or file an appeal.
You can file a complaint with Sentara Medicare or directly with Medicare. To learn more about filing a complaint, contact Medicare member services 1-800-927-6048 (TTY: 711), October 1 through March 31, 7 days a week, from 8 a.m. to 8 p.m. or April 1 through September 30, Monday through Friday, from 8 a.m. to 8 p.m.
Sentara Community Complete Appeals
Request a Coverage Decision
Request a standard decision for a prescription drug. The member, representative, or prescribing physician can submit this request. The request could be for a variety of reasons. Please review the forms for examples.
Sentara Medicare Plans Request for Drug Coverage Determination
Request a Standard decision for Medicare Part D (prescription drugs) electronically
Appeal a Coverage Decision
You can use these forms to request a reconsideration (appeal) of our decision if you disagree with Sentara Medicare's decision to deny your request for coverage or payment for a Part C (medical item or service) or Part D (prescription drug) service. You can also file an appeal through Medicare.gov if you have exhausted your options through Sentara Medicare.
Request a Redetermination (appeal) for a Sentara Community Complete (HMO D-SNP) Prescription Drug
Sentara Community Complete Complaints Packet
File an appeal for medical items or services for Sentara Community Complete (HMO D-SNP)
Appoint a Representative
Appoint a representative who can assist you in filing a complaint, requesting a coverage decision, or filing an appeal.
Appointment of Representative form on CMS.gov
File a Complaint
Instructions for how to file a complaint with Sentara Medicare. A complaint, or grievance, can be filed when you are not satisfied with the quality of care or services you received from your in-network provider or Sentara Medicare. You can also file a complaint directly with Medicare.gov.
Complaint Form from Medicare.gov
Appeal Information from Medicare.gov
Complaint information from Medicare.gov
Who to Contact
Information about the number of Appeals, Grievances & Exceptions filed with Sentara Community Complete:
Sentara Medicare
Appeals and Grievances
PO Box 62876
Virginia Beach, VA 23466
Fax: 1-800-289-4970
TTY: VA Relay Service 1-800-828-1140 or 711