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NaviHealth

 

 

PatientName

MemberAddress

CityStateZip

NaviHealth

 

  Date: LetterGenDateTime

 

Enrollee Name: PatientName

Enrollee ID Number: MemberNumber

  

You Have the Right to an Expedited (Fast) Grievance 

 

You have the right to file an expedited (fast) grievance if:

 

fast  You asked for a fast decision on a service, and we decided to process it under our regular (non-expedited) time frame.  We will give you a fast decision if you resubmit it with a supporting statement from your doctor.

 

fast  You asked for a fast appeal for a service, and we decided to process it under our regular (non-expedited) time frame.  We will give you a fast decision on your appeal if you resubmit it with a supporting statement from your doctor.

 

We need up to 14 days to decide on your request for a service.  Extra days are needed.

reason_request

We need up to 14 more days to consider your appeal for a service.  Extra days are needed.

reason_appeal

 

NOTE: When you request a fast grievance, we will make a quick decision on your request and notify you within 24 hours.

 

How to File an Expedited (Fast) Grievance

 

Call us at «Phone», (TTY 711) Monday through Friday 8 a.m. to 8 p.m.  Eastern to file an expedited grievance or get more information.

 

You can also call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week, for more information about the expedited grievance process.  TTY users should call 711.

 

 

H1111_H2222_H333_12_0555 File & Use (06/25/2012)

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