VillageHealth Health Plan is committed to maintaining high levels of member satisfaction. We continuously strive to improve our services through member feedback. We encourage our members who require assistance with problem solving, to call our Member Services Department at 1-877-586-1648, 7:00 a.m. - 8:00 p.m., 7 days a week. TTY users should call 1-866-525-7833. Another avenue is to use the grievance process. To find instructions on how to complete a grievance click here. If your complaint is about a decision regarding the denial of services or payment, please do not use this form. You will need to file an appeal. Please refer to your Evidence of Coverage (EOC) for detailed instructions on how to file an appeal or call VillageHealth Member Services at 1-877-586-1648, 7:00 a.m. - 8:00 p.m., 7 days a week. TTY users should call 1-866-525-7833. You may use this form when you have a complaint such as: The quality of services that you receive Office waiting times Physician behavior Adequacy of facilities Involuntary disenrollment issues Any other areas of dissatisfaction that do not include coverage decisions If your physician or pharmacist tells you a certain prescription requires a prior authorization or is exceeding a coverage limit, you may fill out the coverage determination form and VillageHealth will assist in having your physician send medical justification to Express Scripts to make a decision on whether to cover your request. Otherwise you may contact VillageHealth Member Services at 1-877-586-1648 (TTY users should call: 1-866-525-7833) for additional assistance in making this request. A decision about whether VillageHealth will cover a Part D prescription drug can be a “standard” coverage determination that is made within the standard timeframe typically within 72 hours. You may ask for a fast decision only if your physician believes that waiting for a standard decision could seriously harm your health or your ability to function. Once a decision has been made, Express Scripts will send a letter to you and your physician regarding the decision of the coverage determination. If your physician or pharmacist tells you a drug is non-formulary or requires a tier exception, you may fill out a coverage determination form and VillageHealth will assist in having your physician send medical justification to Express Scripts to make a decision on whether to cover your request. Otherwise you may contact VillageHealth Member Services at 1-877-586-1648 (TTY users should call: 1-866-525-7833) for additional assistance in making this request. A decision about whether VillageHealth will cover a non-formulary exception or tier exception can be a “standard” coverage determination that is made within the standard timeframe typically within 72 hours upon completed information. If incomplete information is given, the turnaround time will be delayed for up to 14 days. You may ask for a fast decision only if your physician believes that waiting for a standard decision could seriously harm your health or your ability to function. Once a decision has been made, Express Scripts will send a letter to you and your physician regarding the decision of the coverage determination. To check the status of a coverage determination or exception, please contact Member Services at 1-877-586-1648. Member Coverage Determination Link Physician Coverage Determination Link CMS# 062503 © 2003 VillageHealth - VillageHealth 75-2003