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Prospective Members, Enrolled Members

and Provider Inquiries: 800-405-9681 (TTY 711)

Your satisfaction and health are important to us.  We’ll work with you to try to find a prompt resolution of your issue.

Please contact our Member Services number at 1-800-405-9681 for additional information. (TTY users should call 711). Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.

As a member of this plan and as someone who is getting Medicare, you have rights.  We will treat you with respect and take your concerns seriously.  If you would like to obtain a report of the appeals, grievance, and exceptions filed with the plan, you may contact Member Services and request that information.

Appeal and Grievance information is contained within Chapter 9 of the 2021 PPHP Evidence of Coverage document located under the Members menu. If you need personal assistance with any issue, please contact Member Services.

An organization determination is a decision we make about whether items or services are covered or how much you have to pay for those covered items or services.

A Coverage Determination is a decision we make about what drugs are covered and how much you will have to pay for those drugs.

These types of decisions are sometimes called “Coverage Decisions”.  Please refer to Chapter 9 in our Evidence of Coverage which provides detailed information on how you can file an organization determination for medical services and coverage determinations for prescription drugs.

  • CALL:  Please contact our Member Services number at 1-800-405-9681 for additional information. (TTY users should call 711). Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.
  • WRITE: P.O. Box 94290
    Lubbock, TX 79493
  • FAX: 844-593-6221
  • CALL: Please contact our Member Services Department at our Pharmacy Benefit Manager at 1-844-846-8007 for additional information.  (TTY users should call 711)  Our pharmacy Member Services is open 24 hours a day, seven (7) days a week.
  • WRITE:
    • Provider Partners Health Plans
      c/o Elixir
      2181 E, Aurora Road, Suite 201
      Twinsburg, Ohio, 44087
  • FAX: 1-877-503-7231

An appeal is something you request if you disagree with our decision to deny a request for coverage of health care services/prescription drugs, payment of services or for drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are already receiving. For example, you may ask for an appeal if we don’t pay for a drug, item, or service you think you should be able to receive. Chapter 9 in our Evidence of Coverage explains appeals, including the process involved in making an appeal.

You or your appointed representative may request an appeal. You may appoint someone to act on your behalf and serve as your representative for an appeal.  You and your representative must sign the Appointment of Representative Form CMS 1696 (links below) and include this form with your appeal.  The appointment is valid for one year unless revoked.  A copy of this form must be included with any future appeals.

Your doctor can request an appeal for you. For medical care, your doctor can request a coverage decision or a Level 1 appeal on your behalf.   For Part D prescription drugs, your doctor or the prescriber can request a coverage decision or a Level 1 or Level 2 appeal on your behalf.

If you are not happy or if you disagree with a decision we make about what medical care or Part D drug is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appeal. For details on what to do if something is not covered for you in the way you think it should be covered, see Chapter 9 in our Evidence of Coverage. It provides the details on how to make an appeal if you want us to change our decision. Chapter 9 also explains how to make a complaint around quality of care, waiting times, and other concerns.

You must make your appeal request within 60 calendar days from the date indicated on the written notice we sent notifying you of our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include but is not limited to a serious illness that prevented you from contacting us. Another example would be if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.

If you’re health requires it, ask for a “fast appeal” You, your doctor, or your representative must contact us at 1-800-405-9681 TTY 711 or in writing to: PPHP P.O. Box 94290 Lubbock, TX 79493 or fax to 844-593-6221.

If you are asking for a “standard appeal”, make your standard appeal in writing by submitting a request to PPHP P.O. Box 94290 Lubbock, TX 79493 or fax to 844-593-6221.

If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal. Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. If you had a “fast appeal” at Level 1 you will also have a “fast appeal” at Level 2. If you had a “standard appeal” at Level 1, you will also have a “standard appeal” at Level 2.

If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. If the dollar value is high enough, the written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal.

A grievance is a type of complaint you make about us or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

The complaint must be made within 60 days after you had the problem you would like to tell us about.

Call our Member Services number at 1-800-405-9681 for additional information. (TTY users should call 711). Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and fax it to 844-593-6221 or mail it to:

PPHP
P.O. Box 94290
Lubbock, TX 79493

If you are making a complaint because we denied your request for a “fast appeal”, we will automatically give you a “fast complaint.” If you have a “fast complaint,” it means we give you an answer within 24 hours.

Appointing a Representative

You may appoint someone to act on your behalf and serve as your representative on an appeal.  You and your representative must sign the Appointment of Representative Form CMS 1696 and include this form with your appeal.  The appointment is valid for one year unless revoked.  A copy of this form must be included with any future appeals.

If you become incapacitated or legally incompetent, a surrogate may be authorized by the court to act in accordance with State law to file an appeal on your behalf. In this case, an Appointment of Representative Form does not need to be executed. Instead, your surrogate must produce other appropriate legal papers supporting his or her status as your authorized representative when submitted an appeal on your behalf.

You Can Also Get Help From Medicare

For more information and help in handling a problem, you can also contact Medicare by doing one or more of the following:

How to Obtain the Aggregate Number of Grievances, Appeals and Exceptions Filed with PPHP

To obtain the aggregate number of PPHP grievances, appeals and exceptions, please call Member Services at 1-800-405-9681 for additional information. (TTY users should call 711). Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.

Page Last Updated:  10/15/2020

Provider Partner Health Plans are HMO-SNPs with Medicare contracts. Enrollment in Provider Partner Health Plans depends on contract renewal. Y0135_PPHPWEB_2021