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Customer Service: (877) 210-1719
TTY users should call 7-1-1

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Coverage Decisions, Grievances & Appeals

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It is of utmost importance that our members are able to voice their concerns and to have the means of finding a resolution. If there is ever a problem or concern, whether it be with Piedmont Medicare Advantage (PPO), a provider or even with your prescription drugs, you have options.

We encourage you to contact Customer Service to resolve any issue. They can be reached by phone at 434-947-3671 or toll-free 1-877-210-1719 from 8:00 a.m. to 8:00 p.m., seven days a week from October 1 through February 14. From February 15 through September 30, Customer Service is available 8:00 a.m. to 8:00 p.m., Monday through Friday. TTY users should call 7-1-1.

What is a coverage decision?

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. You or your doctor can contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular service or refuses to provide medical care you think that you need. 

When a coverage decision involves your medical care, it is called an Organization Determination
When a coverage decision involves your Part D drugs, it is called a Coverage Determination

We are making a coverage decision for you whenever we decide what is covered for your and how much we pay.  In some cases, we might decide a service or drug is not covered or no longer covered by Medicare for you.  If you disagree with this coverage decision, you can make an appeal.

What is an appeal?

If we make a coverage decision that you are not satisfied with, you can file an “appeal.” You may file an appeal if you disagree with our decision to deny a request for coverage of health care services, prescription drugs, or payment for services or drugs you already received. You may also file an appeal if you disagree with our decision to stop services you are receiving.

Once we receive your appeal, we will review the coverage decision. Your appeal is handled by different reviewers than those who made the original decision. We will notify you of the decision upon completion of our review.

If we deny all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to us.

What is a grievance?

A grievance is a type of complaint that you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of care. It can also include problems related to wait times, the customer service you receive, or the timeliness of our actions related to coverage decisions and appeals.

When you file a grievance, we review your complaint and provide you with a response including a description of the reason for our decision.

All of these processes have been approved by Medicare. To ensure the fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you.

The complete coverage decisions, grievance and appeals process can be found in Chapter 9 of the Annual Notice of Change/Evidence of Coverage or CLICK HERE.

Prescription Drug Coverage Decisions, Grievances and Appeals

For prescription drug coverage decisions, otherwise known as a Part D coverage determination, call 24 hours a day, 7 days a week at:
  • 1-866-494-9927
  • TTY users should call 7-1-1

You may submit your coverage determination request via fax at 1-855-633-7673. Or you may send it to us in writing to:

Piedmont Medicare Advantage
MC 109, P.O. Box 52000
Phoenix, AZ 85072-2000

For prescription drug grievances call 24 hours a day, 7 days a week at:
  • 1-866-494-9927
  • TTY users should call 7-1-1

You may send your grievance in writing to:

Piedmont Medicare Advantage
Grievance Department
P.O. Box 53991, MC 121
Phoenix, AZ 85072-3991

For prescription drug appeals call 24 hours a day, 7 days a week at:
  • 1-866-494-9927
  • TTY users should call 7-1-1

You may submit an appeal via fax at 1-855-633-7673. Or you may send it to us in writing to:

Piedmont Medicare Advantage
Prescription Drug Plans Appeals Department
MC 109
P.O. Box 52000
Phoenix, AZ 85072-2000

Medical Coverage Decisions, Grievances and Appeals

For medical coverage decisions, also known as a Part C organization determination, call:
  • 434-947-3671
  • 1-877-210-1719 (toll-free)
  • TTY users should call 7-1-1

Customer Service is available by phone 8:00 a.m. to 8:00 p.m., seven days a week from October 1 through February 14. From February 15 through September 30, Customer Service is available 8:00 a.m. to 8:00 p.m., Monday through Friday. Our local office is open for walk-in customer assistance from 8:30 a.m. to 5:00 p.m., Monday - Friday, except for holidays.

You may submit an organization determination request via fax at 1-434-947-4465. Or you may send it to us in writing to:

Piedmont Medicare Advantage
Coverage Decision Department

2316 Atherholt Road
Lynchburg, VA 24501

For medical grievances and appeals call:
  • 434-947-3671
  • 1-877-210-1719 (toll-free)
  • TTY users should call 7-1-1

Customer Service is available by phone 8:00 a.m. to 8:00 p.m., seven days a week from October 1 through February 14. From February 15 through September 30, Customer Service is available 8:00 a.m. to 8:00 p.m., Monday through Friday. Our local office is open for walk-in customer assistance from 8:30 a.m. to 5:00 p.m., Monday - Friday, except for holidays.

You may submit a grievance/appeal via fax at 1-434-947-4465. Or you may send it to us in writing to:

Piedmont Medicare Advantage
Grievance/Appeals Department
2316 Atherholt Road
Lynchburg, VA 24501

Medicare Ombudsman

Forms you may need:

Appointment of Representative Form CMS-1696
Request for a Medicare prescription Drug Coverage Determination
Coverage Determination Request Form for Physicians
Redetermination Request Form
Medicare Complaint Form

For a complete list of downloadable forms, CLICK HERE

To request an aggregate number of grievances, appeals, and exceptions filed with Piedmont Medicare Advantage, This email address is being protected from spambots. You need JavaScript enabled to view it. 

Piedmont Medicare Advantage is a PPO plan with a Medicare contract. Enrollment in Piedmont Medicare Advantage depends on contract renewal. Out-of-network/non-contracted providers are under no obligation to treat Piedmont Medicare Advantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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Last Updated: 05/31/2018