Medicare Part C Appeals

Providers may appeal claims where Care Improvement Plus has denied all or part of a claim. All appeals must be in writing and submitted within 60 days, or as stipulated in the provider's contract, from the date payment was denied. The provider must send all necessary medical documentation to support medical necessity and appropriateness of care for review by the Plan's clinical evaluation team and a licensed physician. Care Improvement Plus will send a written decision within 60 days of the receipt date. For non-contracted providers, the receipt date begins as soon as both the written appeal request and Waiver of Liability form are received by the Health Plan.

Provider and Member Appeals: Members have appeal rights that begin with plan-level reconsideration and extend through four (4) additional levels of external review. Providers may appeal on behalf of a member, but only in the limited circumstances as allowed by federal law, as follows:

Expedited Part C Appeals: Physicians may request an expedited appeal on behalf of the member. Expedited appeals are cases where denied medical services are of an urgent nature. That is, a delay in obtaining the medical services could jeopardize the member's health, life, or ability to regain maximum function. Expedited appeals do not have to be in writing and may be initiated by calling 1-800-213-0672. Expedited appeals regarding certain medications that have restrictions and are given in the Doctor's office may be initiated by calling 1-866-904-6561.

Appointment of Representative (AOR): Providers may serve as the "official" representative of the member by signing, along with the member, a CMS Form 1696. A letter that includes the same designation of authority and co-signed with the member may also be used. Once activated, an authorized representative has the same rights as a member in the Medicare member appeals process.

Appeals regarding certain medications that have restrictions and are administered in the Doctor's office may be faxed or mailed to the following address:

Care Improvement Plus
Attn: Pharmacy Part C Appeals
351 West Camden Street, Suite 100
Baltimore, MD 21201
Fax: 1-866-272-2942

The Waiver of Liability Form and Appointment of Representative Form (CMS Form 1696) is located under the FORMS section of our website. For more information on how to file an appeal, please call Provider Services at 1-866-679-3119; TTY users should call 1-800-713-1603.