MEDICARE PART D APPEALS AND GRIEVANCES
Part D Appeals
If a member or her/his physician disagrees with any coverage determination including a formulary exception, or if Care Improvement Plus fails to provide a timely decision on a coverage determination, the member or his/her physician has the right to file an appeal in writing. See the Helpful Resources page for contact details. If a delay in treatment due to the denial could jeopardize a member’s health status, an expedited appeal may be requested by phone, fax or email.
The first level of a prescription drug appeal is a "redetermination" and is reviewed by the plan's pharmacists and physicians. Care Improvement Plus must gather information and make a determination within a 7-day time period for a standard appeal or within 72 hours for an expedited appeal. Redeterminations for denied claims are decided within 7 days.
If Care Improvement Plus upholds its initial denial, a member will receive a written notice, including how to file an appeal at the next level. The second level of appeal is conducted by Medicare's independent review contractor, and is called a reconsideration. If the independent reviewer agrees with the health plan's denial, members have the same rights to the federal levels of appeals and judicial review as do beneficiaries in fee-for-service Medicare.
Request for Medicare Prescription Drug Redetermination Form
For appeals related to prescription drug coverage physicians, members or authorized representatives may submit a letter or use the following: Request for Medicare Prescription Drug Redetermination Form.
Grievances
If a member is dissatisfied or has a complaint about any aspect of Care Improvement Plus, he/she may call or write our Member Services department. Complaints other than those involving coverage determinations are called grievances. (Complaints about denials and other adverse coverage determinations are handled as appeals, and are not grievances.) We will investigate the grievance and respond in a timely manner. Complaints about denied requests for an expedited decision or appeal, or disagreements over time extensions, will be handled as expedited grievances - they are reviewed and resolved within 24 hours.
This page was last updated on: 9/27/2011 10:51:26 AM