MEDICARE PART D APPEALS AND GRIEVANCES

Part D Appeals
If you or your physician disagrees with any restriction, limitation, or denial of a prescription, or if Care Improvement Plus fails to provide you with a timely decision about a prescription, you have the right to file an appeal in writing. See the Helpful Resources page for contact details. If a request for an exception to some provision of the formulary is denied, you have the right to appeal. If the restriction or denial could jeopardize your health status, you may request an expedited appeal by phone or fax.

The first level of a prescription drug appeal is a "redetermination" and is conducted 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 expedited appeals. Redeterminations for denied claims are decided within 7 days. You are notified of the decision.

If Care Improvement Plus upholds its initial denial, you 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, you have the same rights to the federal levels of appeals and judicial review as do beneficiaries in fee-for-service Medicare.

Grievances
If you are dissatisfied or have a complaint about any aspect of Care Improvement Plus, you 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 to you 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.