Member Resources

Thank You for being a Member of West Virginia Senior Advantage

Member Resources provides you with the tools, information and resources to help you get the most out of your West Virginia Senior Advantage benefits, coverage and, much more.

  • To request a hardcopy of the West Virginia Senior Advantage provider directory or the Evidence of Coverage, please call Member Services at 1-844-854-6888, TTY 711
  • To learn about your members rights and responsibilities, please see Chapter 8 of your Evidence of Coverage.

As a member of West Virginia Senior Advantage, you must use network providers. If you receive unauthorized care from an out-of-network provider, we may deny coverage and you will be responsible for the entire cost.
Here are three exceptions:

  • The plan covers emergency care or urgently needed care that you get from an out- of-network provider. For more information about this, and to learn what emergency or urgently needed care means, please contact Member Services.
  • If you need medical care that 1) Medicare requires our plan to cover, and 2) the provider in our network cannot provide this care, you can get this care from an out- of-network provider. Prior Authorization should be obtained from the plan prior to seeking care. In this situation, if the care is approved, you would pay the same as you would pay if you got the care from a network provider. Your PCP or other network provider will contact us to obtain authorization for you to see an out-of- network provider.
  • Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. In these special circumstances, it is best to ask an out-of-network provider to bill us first. If you have already paid for the covered services or if the out-of-network provider sends you a bill that you think we should pay, please contact Member Services or send us the bill.

What Is an Appeal?

An appeal is a formal request by the member (or his/her authorized representative) to change a decision previously made by West Virginia Senior Advantage.
For example, you may file an appeal for any of the following reasons:

  • West Virginia Senior Advantage refuses to cover or pay for services you think West Virginia Senior Advantage should cover.
  • West Virginia Senior Advantage or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
  • West Virginia Senior Advantage or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
  • If you think that West Virginia Senior Advantage is stopping your coverage too soon.

Who Can File an Appeal?

You or your authorized representative may file an appeal. You may also have your physician file an appeal on your behalf.

You may appoint an individual to act as your representative to file the grievance or an appeal for you by following the steps below.

Provide our health plan with:

  1. Your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: “I [your name] appoint [name of representative] to act as my representative in requesting an appeal from West Virginia Senior Advantage and/or CMS regarding the denial or discontinuation of medical services.”
  2. Your name, address and phone number and that of your representative, if applicable.
  3. A signed and dated statement by you and the person you are appointing as representative
  4. You must include this signed statement with your appeal.
  5. Reasons for appealing, and any evidence you wish to attach.
  6. Supporting medical records, doctors’ letters, or other information that explains why your plan should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.

When Can an Appeal Be Filed?

You may file an appeal within sixty (60) calendar days of the date of the notice of the initial organization determination.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day time frame.

Can I Expedite an Appeal?

You have the right to request and receive expedited decisions affecting your medical treatment in “time-sensitive” situations. This will be considered a fast appeal.

A “time-sensitive” situation is a situation where waiting for a decision to be made within the time frame of the standard decision-making process could seriously jeopardize 1) your life or health, or 2) your ability to regain maximum function.

If West Virginia Senior Advantage decides, based on medical criteria, that your situation is “time-sensitive” or if any physician calls or writes in support of your request for an expedited review, West Virginia Senior Advantage or your Primary Care Physician will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request.

Where Can an Appeal Be Filed?

You may file a standard or fast appeal to: West Virginia Senior Advantage, Appeals and Grievances Department, PO Box 94390 Lubbock, TX 79493, Phone 1-844-854-6888; TTY 711, Fax 1-800-903-0271.

What Happens Next?

We will review your appeal. If any of the services you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by a reviewer outside of West Virginia Senior Advantage. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.

What Is a Grievance?

A grievance is a type of complaint that does not involve payment or denial of services by West Virginia Senior Advantage or a Contracting Medical Provider. For example, you would file a grievance if:

  • You have a problem with things such as the quality of your care during a hospital stay;
  • You feel you are being encouraged to leave your plan;
  • Waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room;
  • Waiting too long for prescriptions to be filled;
  • The way your doctors, network pharmacists or others behave;
  • Not being able to reach someone by phone or obtain the information you need; or
  • Lack of cleanliness or the condition of the office.

Who Can File a Grievance?

A grievance may be filed by any of the following:

  • You may file a grievance.
  • Your authorized representative.

Why File a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with West Virginia Senior Advantage or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding, or lack of information.

Can I Expedite a Grievance?

Yes. If you disagree with West Virginia Senior Advantage’s decision to extend the timeframe on your organization determination or reconsideration, or West Virginia Senior Advantage’s decision to process your expedited request as a standard request. In such cases, you may file an expedited grievance and receive a response within twenty-four (24) hours of receipt.

Where can a Grievance Be Filed?

You may file a standard grievance in writing directly to: West Virginia Senior Advantage -Appeals and Grievances Department, PO Box 94390 Lubbock, TX 79493.

You may file a standard or expedited grievance by fax to 1-800-903-0271 or over the phone by contacting our Member Services Department at our toll-free number at 1-844-854-6888. Our hours are between 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

If you would like you can file a complaint directly to Medicare by filling out the complaint form at https://www.medicare.gov/MedicareComplaintForm/home.aspx.

You have the right to request the number of appeals and the number of quality of care grievances received by West Virginia Senior Advantage (HMO SNP) during a plan year.

Please call Member Services at 1-844-854-6888 (TTY 711), Fax 1-800-903-0271.

Our hours are 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Calls to this number are free.

You or someone you name may file a complaint (grievance) or appeal for you. The person you name would be your “appointed representative”. You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act on your behalf.

To appoint a representative, fill out the CMS Appointment of Representative Form (CMS Form-1696)Once you have filled out the form, you may print and mail the form to:

West Virginia Senior Advantage PO Box 94390 Lubbock, TX 79493 You may also send a fax to 1-800-903-0271

A description of, and information on how to appoint a representative, you may also call Member Services for West Virginia Senior Advantage at 1-844-854-6888; TTY 711. Our hours are 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Calls to this number are free.

Ending your Membership in West Virginia Senior Advantage may be voluntary (your own choice) or involuntary (not your own choice). If you are leaving our plan, you must continue to get your medical care through our plan until your Membership ends.

Your disenrollment will usually be effective on the first day of the month after we receive your written request to end your Membership. You can choose another Medicare health plan or Original Medicare. Your enrollment in your new plan will begin on the first day of the month after you end your enrollment with us.

For more complete information about disenrolling from West Virginia Senior Advantage, you can do any of the following:

  • See chapter 8 of your Evidence of Coverage for more information and to learn about the rights, benefits, and responsibilities of Members.
  • To request a disenrollment form, call West Virginia Senior Advantage at 1-844-854-6888; TTY 711. Calls to this number are free. Our hours are 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.)
  • Read the Medicare & You Handbook. Everyone with Medicare receives a copy of Medicare & You each fall. Those new to Medicare receive it within a month after first signing up. You can also download a copy from the Medicare website (www.medicare.gov). Or, you can order a printed copy by calling Medicare at the number below.
  • Contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Calls to these numbers are free.
 
 

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Can’t find what you are looking for or need to check the status of your request?

For more information, please call us at:

West Virginia Senior Advantage
1-844-854-6888 (TTY 711)

Our hours are 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Calls to this number are free.