Coverage Rights and Responsibilities

Troy is committed to making sure you get the medical care you need. Your experience is important to us. If you experience unhappiness or dissatisfaction with Troy, a plan provider or staff, or your coverage, you have certain rights.

Important Definitions: 

Coverage Decision:  A decision Troy Medicare makes about your benefits and coverage (called a prior authorization) following a request by you or your doctor before you receive the service, medication, or item. In some cases, Troy Medicare might decide a service or drug is not covered, is not right for your care, or is not covered by Medicare. If you disagree with this coverage decision, and you are not satisfied, you can ask us to review the decision again. This process is called a “Level 1 Appeal”.  

Payment Decision: A decision Troy Medicare makes about payment to a provider for your health care or to you if you request us to reimburse out of pocket expenses that should have been paid by Troy Medicare. 

Appeal:  A formal way of asking Troy Medicare to review and change a coverage decision we have made. When you send us a Level 1 appeal, we review the coverage or payment decision we made to see if our first decision was correct. We will send you written notice of our decision, or we will send your appeal for Level 2 appeal review decision by a third-party independent reviewer.

Grievance:  A complaint, expressing dissatisfaction with any part of the operations, activities, or behavior by Troy Medicare, or its delegated entity or health care provider when providing benefits, prescription drugs, or services, regardless of whether a resolution can be taken. A grievance may also be about whether proper health care services have been provided to you.

How to make a complaint (grievance):

1. Contact Member Services as soon as possible either by telephone or in writing. We must receive your complaint within 60 days of the event that caused the complaint. 

2. Call Member Services at 1-888-494-TROY (8769) or TTY 711. We are available 8am-8pm Eastern Time, Monday – Friday, and from October 1 through March 31, we are available 7 days a week. We will take your complaint and try to give you an answer on the same phone call.  If we cannot resolve your complaint on the phone call, we have up to 30 days to resolve it. If we need more time to resolve the complaint, we will notify you.

3) Send us your signed written complaint or print the Provider Dispute and Appeal Form: or Provider Dispute and Appeal Form (Fillable):

• FAX to: 910-839-8320
• Mail to:  
  ‍Troy Medicare 
  Attn: Appeals & Grievances
  PO Box 1265 Westborough, MA 01581

5) You can also tell Medicare about your complaint.  You can send a complaint about Troy Medicare directly to Medicare on their website. To send a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx

6) You may also call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048, 24 hours a day, 7 days a week.

For more information about grievances, please see the Evidence of Coverage, Section 10.3.

You have the right to make a complaint if we let you know that we ended your membership in our plan.  We must tell you our reasons in writing for ending your membership and actions you can take if you believe the information is wrong. We must also explain how you can make a complaint about our decision to end your membership. Call Member Services if you need further help. 

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Your Right to Appoint a Representative

You can ask someone to act on your behalf if you need something to help you make a complaint, ask for a coverage decision from Troy Medicare, or file a Level 1 appeal.  If you want a friend, relative, or other person to be your representative, call Member Services and ask for the “Appointment of Representative” form. 

You can also use this link to the form www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf  It must be signed by you and by the person who you would like to act on your behalf. Your appointed representative must send us this form with the complaint or the request for a coverage/payment decision or appeal. This form does not give the appointed person any other rights but to stand in for you for these purposes. 

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How to ask Troy for a Payment Decision:

If you need Troy Medicare to reimburse you for a health care service that you've paid for, you will need to ask for a payment decision from us.  Follow these steps:

To make a payment decision, we will check to see if the medical care you paid for is a covered service. We will also check to see if you followed all the rules for using your coverage for medical care.

This Member Reimbursement form is available for our members of Troy Medicare plans to submit requests for reimbursement; please use this form or if you have questions on other ways to submit or how to use this form, please contact Member Services.

• If we say yes to your request: we will send you the payment for our share of the cost within 30 calendar days after we receive your request. 

• If we say no to your request: we will not send payment. Instead, we will send you a letter that says we will not pay for the services and the reasons for our decision. This letter will include your right to appeal our decision.

If you do not agree with our decision to deny your request, you can file an appeal. If you send us an appeal, it means you are asking us to change the payment decision we made when we turned down your request for payment.

We must receive your appeal within 65 calendar days from the date on the written notice we sent you with our denial of the payment decision. If you miss this deadline and have a good reason (called a “good cause”) for missing it, explain the reason your appeal is late when you make your appeal. Examples of a good cause may include a serious illness for you or a family member that delayed you from sending your appeal.  

We will decide on your payment appeal and let you know the answer within 60 days of receipt:  

• If we say yes to your request: we will send you the payment for our share of the cost within 60 calendar days after we receive your request. 

• If we say no to your request: we will not send payment. Instead, we will send you a letter that says we denied your request and we sent your appeal to an independent third-party reviewer.

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You have the Right to Ask for a Coverage Decision:

In most cases, your Primary Care Provider will send a request for a coverage decision on your behalf to Troy Medicare. They will provide us with the necessary medical information we need to approve the request. If you have questions about this process, call Member Services or ask your provider. 

You also have the right to request a coverage decision if you believe the item or service should be given or arranged by Troy Medicare. We will provide you with a decision within either 72 hours (expedited) or 14 calendar days (standard) unless we need an extension of the timeframe. We will contact you if the decision will be delayed and give you your rights to file an expedited grievance.

You or your appointed representative may send us a letter or a completed Prior Authorization Request form.

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• If we say yes to your request: This means, we decided that the medical care is covered, and we authorize the servicing provider to give you the service or item. We will call you and send a letter to you and to the servicing provider.

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• If we say no to your request: This means, we did not receive enough information from the provider(s) to approve your request or did not find the service was medically necessary. We will call you and send you a letter that says we did approve your request and the reasons why we made the decision. This letter will include your right to appeal our decision. 

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You have the right to Appeal our Coverage/Payment Decision

The following parties to the coverage decision may appeal (called a “reconsideration”): 

You have the right to appeal if you receive notice of any of the following:

• Troy Medicare denied payment for emergency services, renal dialysis, post-stabilization care or urgently needed care while you were temporarily out of the service area. 
• Troy Medicare refused to authorize, provide, or reimburse you for services, in whole or in part, that you believe should be covered. 
• Troy Medicare failed to approve, furnish, arrange for, or provide payment for services in a timely manner.

Once you receive written notice, you may file an appeal within 65 days from the date of the letter. A special team will review the appeal to determine if we made the right decision. 

Submit your signed written appeal to Troy Medicare. You can put the request in a letter or complete this form and mail to:

• FAX 910-839-8320 (be sure to use a cover letter to protect your information).
• Mail to:  
  Troy Medicare 
  Attn: Appeals & Grievances
  PO Box 1265 Westborough, MA 01581

Share information about the coverage or payment decision, and why you think the denial is incorrect. Include any documentation, including the Appointment of Representative form if applicable. 

We will review your case and provide you with a decision within the timeframe allowed by Medicare, up to 60 calendar days, depending on the type of appeal. Some cases require a faster review timeframe. 

• If we overturn the original coverage decision: this means that we agree with you and decide the case in your favor. We will send you a letter and authorize either  the coverage or payment. 
• If we uphold the original coverage decision, this means we believe the original coverage decision was right. We will send the case to an independent third-party reviewer. They will inform you of the final decision and any other appeal rights if applicable.

Disenrollment Rights and Responsibilities