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National Home Providers Medicare Part C

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.

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.

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 711.



This page was last updated on: 11/20/2014 8:34:53 PM

Copyright © 2006 - 2015 Care Improvement Plus

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Medicare evaluates plans based on a 5-Star rating system. Star ratings are calculated each year and may change from one year to the next.

Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity and restrictions may apply. It may cost more to get care from out–of–network providers, except in an emergency. If there isn’t a network provider available for you to see, you can go to an out–of–network provider but still pay the in–network amounts. The health providers in our network can change at any time.

To be eligible for a Care Improvement Plus Regional PPO plan you must be a Medicare beneficiary living in Arkansas, Georgia, Missouri, South Carolina, or Texas and have both Medicare Part A and Part B to enroll.

To be eligible for a Care Improvement Plus Local PPO plan you must be a Medicare beneficiary living in select counties of: Arkansas, Georgia, Illinois, Indiana, Iowa, Missouri, Nebraska, New Mexico, North Carolina, South Carolina, Texas or Wisconsin and have both Medicare Part A and Part B to enroll.

To be eligible for a Care Improvement Plus Chronic Conditions Special Needs Plan, you must have diabetes and/or heart failure and/or, cardiovascular disorder. This plan is available to anyone having a qualifying chronic care condition. Members may enroll in the plan only during specific times of the year. Contact Care Improvement Plus for more information. If you have diabetes, heart failure, cardiovascular disorder or Medicaid/Low Income Subsidy, you may qualify to enroll in a Care Improvement Plus Special Needs Plan ANYTIME of the year by exercising a “Special Election Period.

To be eligible for a Care Improvement Plus Dual Advantage Plan, you must be enrolled in state Medicaid and be a dual eligible beneficiary whom the State holds harmless for Part A and Part B cost sharing. This plan is available to anyone who has both medical assistance from the state and from Medicare. If you are a full benefit dual beneficiary and your Part B premium is paid for by the State, you will not be responsible for paying your Part B premium. Premiums, copays, co-insurance and deductibles may vary based on the level of extra help you receive. Please contact the plan for further details.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call:

  • 1–800–MEDICARE (1–800–633–4227). TTY users should call 1–877–486–2048, 24 hours a day/7 days a week;
  • The Social Security Office at 1–800–772–1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1–800–325–0778; or
  • Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1– 800–772–1213.TTY users should call 1–800–325–0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a part of this premium, we will bill you for the amount that Medicare doesn’t cover.


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