Advocate FAQ

 

Q.  What is an advocate?

 

A.  A Medicare-Medicaid trained individual who investigates complaints regarding (Medicare-Medicaid) health care issues or billing issues against a health plan or provider.

 

Q.  What is the Prime advocate's role?

 

A.  An independent and neutral mediator, who investigate a dispute and makes recommendations but who cannot reverse a decision/denial.

 

Q.  What services does the Prime advocate provide?

 

A.  Assist consumers in understanding their rights and responsibilities as Medicare-Medicaid health plan members, including grievance and appeals processes.  Assist consumers in analyzing and resolving problems concerning health care bills and health coverage.  Help in filing a complaint and assisting with complaints elevated to Medicaid fair hearings.  Make appropriate referrals to other agencies and work jointly with consumers in seeking resolution or assistance.

 

Q.  Who can use Prime advocate services?

 

A.  Dual Eligible consumers (with both Medicare and Medicaid) aged 65 and older, their caregivers, family and friends are eligible to obtain Prime Advocates services.

 

Q.  Where can I find a Prime advocate?

 

A.  The Health Connections website is very robust with information on the services and partnerships and other related resources.  Prime Advocate brochures and other materials are distributed through community outreach events including faith-based organizations.  Call 1-844-477-4632 or e-mail the Prime advocate at primeadvocate@aging.sc.gov.

 

Q.  If I file a complaint, can I remain anonymous? 

 

A.  Yes, unless the complaint rises to the legal/court level, where the caller maybe identified.  Yes, unless the caller is at risk of harming themselves or others due to the complaint.

 

Q.  What if I cannot reach my care coordinator?

 

A.  The ombudsman will assist in contacting the health plan to access/review care coordinator issues to seek resolution for the lack of contact and to discuss compatibility concerns.

 

Q.  Can the Prime advocate assist consumers in skilled nursing or disability and special needs facilities?

 

A.  Although, the Prime Advocates/Program is co-located in the Division of Long-term Care Ombudsman; they are not certified to contact consumers in residential care facilities.  However, Prime Advocates works in tandem with the state and regional long-term care ombudsmen to educate consumers and provide assistance.

 

Q.  What can a Prime advocate not do?

 

A.  The Prime Advocate cannot decide the outcome of a complaint.  The Prime Advocate cannot  determine eligibility for Medicaid or Medicare.

 

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