Online Member Request, Appeal or Complaint Form

Online Member Request, Appeal or Complaint Form
Please fill out the form below to request a coverage decision, appeal, or to file a formal complaint for any part of care or service you had from OneCare. Click “Submit” to make sure your information is right before you submit your form. If you have any problems filling out this form, please call OneCare Customer Service Department at 1-877-412-2734.

If you wish to have someone represent you, other than your doctor, you must submit an Appointment of Representative Form or a legal document authorizing a representative to act on your behalf.

* = Mandatory Fields
Date of Complaint: Sunday, September 24, 2017
 
*Date of Incident/Denial: / /  
 
 
 
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Please take some time to review this form to make any changes or add more information. If you have any problems filling out this form, please call OneCare Customer Service Department at 1-877-412-2734.
Thank you for taking time to share your concerns with OneCare. Please read your OneCare Evidence of Coverage for more information on your member rights, health coverage and available services.

Date Revised December 26, 2014

To file a complaint with Medicare, click on the following link to complete a complaint form on the Medicare website: Medicare Complaint Form.

H5433_WEB1004 Approved (11/15/16)

OneCare (HMO SNP) is a Medicare Advantage organization with a Medicare contract. Enrollment in OneCare depends on contract renewal. Eligible beneficiaries can enroll at any time. Eligible beneficiaries must have Part A and Part B to enroll in the plan. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. Co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. Other Pharmacies/Physicians/Providers are available in our network. Medicare beneficiaries may also enroll in OneCare (HMO SNP) through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. Medicare has neither reviewed nor endorsed this information. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. OneCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This information is available for free in other languages. Please call our customer service number at 1-877-412-2734, 24 hours a day, 7 days a week. TDD/TTY users should call 1-800-735-2929.

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