MEDICARE PART D APPEALS AND GRIEVANCES
Part D Appeals
If you or your physician disagrees with any coverage determination including a formulary exception, or if Care Improvement Plus fails to provide you with a timely decision on a coverage determination, you have 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 your health status, you may request an expedited appeal 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, 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.
Request for Medicare Prescription Drug Redetermination Form
For appeals related to prescription drug coverage you may submit a letter or use the following: here.
For more information on how to fill out the Coverage Determination Request form here.
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.
This page was last updated on: 9/15/2011 4:09:46 PM