Member Services Representatives are available to assist you 8 a.m. to 8 p.m., 7 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.
1-866-634-2247, TTY/TDD: 711
Members Rights & Responsibilities
Appointment of Representative (AOR) - (CMS-1696)
You may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as your representative and file an appeal and/or grievance on your behalf. To appoint someone, both you and appointed representative accepting the appointment (including attorneys) must sign, date, and complete a representative form.
To download the form (CMS-1696), click here.
Please mail this form to:
Alignment Health Plan HMO
1100 Town And Country Rd, STE 1600
Orange, CA. 92868
For more information about how to file a formal complaint or appeal regarding any aspect of the medical care or service provided to you, please click here
. Your complaint or appeal may be in reference to your medical or pharmaceutical benefits.
You may also submit feedback or complaints about your Medicare Advantage health plan directly to Medicare by submitting a compliant via www.medicare.gov
or by calling 1-800-Medicare.
Organization Determination Process
The process for coverage decisions and appeals can be found in Chapter 9 of your evidence of coverage (EOC). This is the process you use for issues such as whether something is covered or not and the way in which something is covered. Please refer to Chapter 9 of your EOC for a full description of the process. Evidence of Coverage
You can also access this information by downloading Chapter 9 here.
You may qualify for extra help, also called the low-income subsidy (LIS), from Medicare to pay prescription drug costs if your yearly income and resources are below the limits set.
View LIS Levels
For information on how to obtain an aggregate number of grievances, appeals and exceptions filed with our plan, please contact our Member Services Department at the number below. If you are a member or contracted provider with questions about the Appeals and Grievance process, or have questions about the status of a filed Appeal or Grievance, please contact Member Services at
1-866-634-2247, TTY/TDD: 711
8 a.m. to 8 p.m., 7 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.
In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. You are responsible for paying the full cost of services that aren't covered by our plan, either because they are not plan covered services, or they were obtained out-of-network and were not authorized.
Here are three exceptions:
When can you use a pharmacy that is not in the plan's network?
Your prescription may be covered in certain situations
- The plan covers emergency care or urgently needed care that you get from an out-of-network provider.
- If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. Prior authorization is required before you get care from an out-of-network provider. In this situation, you will pay the same as you would pay if you got the care from a network provider. For information about getting approval to see an out-of-network doctor, see Section 2.4 of your Evidence of Coverage book.
- Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan's service area.
We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- If you are unable to get a covered drug in a timely manner within our service area, because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
- If you are trying to fill a covered prescription drug that is not regularly stocked at a network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals.
In these situations, please check first with Member Services to see if there is a network pharmacy nearby.
How do you ask for reimbursement from the plan?
If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. (Please see Chapter 7, Section 2.1 of your Evidence of Coverage book for a description of how to ask the plan to pay you back.)
Page last updated on 10/7/2020 | Y0141_21079EN