Grievances & Appeals

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Coverage Decisions, Appeals and Complaints

 
Contact information

Our Customer Service representatives for your plan are available to assist you with any questions you may have.


How to appoint someone to act on your behalf

You or your physician may request an initial determination or file a grievance or appeal. You may name a relative, friend, advocate, doctor or anyone else as your “appointed representative” to act for you. You may already have a representative authorized under State law to act for you; however, if you want someone to act for you, you and your representative must sign and date a statement giving the person legal permission to be your appointed representative. The form is available below. Please contact your plan for more information.

Appointment of Representative Form


How to obtain a coverage decision

Medical - Organization Determination

An Organization Determination is a coverage decision for Medical Care. The Medicare Advantage plan has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. The Medicare Advantage plan’s network provider or facility has also made an organization determination when it provides you with an item or service, or refers you to an out-of-network provider for an item or service. Organization determinations may also be called “coverage decisions”.

Here is how to request coverage for the medical care you want
 

  • Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this.

  • Our contact information (phone number, address, and fax number) is available to you on the contact us page of this website and in the plan’s Evidence of Coverage (EOC). You can also call us using the number on the back of your id card.


Additional information regarding requesting an Organization Determination is provided in the plan’s EOC.

Medical - Appeal rights
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

There are two kinds of appeals you can request:
 

Expedited (72 hours) - You can request an expedited (fast) appeal for cases that involve medical coverage determinations if you or your doctor believes that your health could be seriously harmed by waiting up to 30 days for a decision. If your request to expedite is granted, we must make a decision no later than 72 hours after receiving your appeal. 

Standard (30 - 60 days)
- You can request a standard appeal for a case that involves medical coverage or payment determinations. We must give you a decision no later than 30 days after receiving your appeal for coverage appeals or 60 days for claims payment appeals.
 

What Do I Include with My Appeal?
You should include your name, address, and Member ID number. You should also include the reasons for your appeal, and any evidence you wish to attach.

How Do I Request an Appeal?
To start an appeal, you, your doctor, or your representative must contact us.


For an Expedited Appeal: We suggest contacting us be telephone. Be sure to ask for a “fast or expedited review.” This means you are asking us to give you an answer using the expedited deadlines rather than the standard deadlines.

For a Standard Appeal: Make your standard appeal in writing by submitting a request.
Standard appeals must be in writing. Please send your appeal to us at the address below.

Medicare Appeals & Grievances Department
P.O. Box 7776
London, KY 40742
Fax: 1-855-788-3994


For more information about your appeal rights, call Customer Service at the number located on the back of your ID card, refer to the Evidence of Coverage, or visit the contact us page of this website.


Medicare Non Participating Provider Appeal Rights

Payment Appeals Submission Requirements and Review Process:
If the non-contracted Medicare health plan provider disagrees with a claim payment denial, they have 60 calendar days from the initial organization determination date to file a written payment appeal.

A written request for a payment appeal along with any supporting documentation and a completed Waiver of Liability form must be sent to Appeals & Grievances Mailing Address:

Medicare Appeals & Grievances Department
P.O. Box 7776
London, KY 40742

Upon receipt of a valid request for a payment appeal, the plan has 60 calendar days to review and respond. Note that in order to be considered a valid payment appeal, the request must include a completed and signed Waiver of Liability (WOL) form. If the WOL is not submitted or complete, the request will be sent to CMS’ Independent Review Entity for dismissal at the end of the appeal timeframe.

Waiver of Liability (WOL) Form  (example)

If the plan upholds the initial determination in whole or in part, the plan must forward the case to CMS’ Independent Review Entity (IRE) for a second level review. The current IRE for payment appeals is Maximus Federal Services. The IRE will review the case and send a resolution to the provider and the plan. 


Prescription Drug – Coverage Determinations and Exceptions

Our plan uses different types of restrictions to help our members use drugs in the most effective ways.

Prior Authorization: Approval in advance to get certain drugs that may or may not be on our formulary.

Step Therapy: A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.

Quantity Limits: A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.

For more detailed information on plan restrictions, please visit Prior Authorization section of our website. Continue reading below for information on coverage determinations and exceptions.


Coverage Determinations

A coverage determination is a decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are also called “coverage decisions”. See the plan’s Evidence of Coverage document for more details about coverage determinations.

Under the Medicare Part D prescription drug benefit program, a beneficiary can request a coverage determination regarding the drug benefits they are entitled to receive. When Coventry makes a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what the beneficiary's share of the cost is for the drug. A beneficiary enrolled in a Part D plan may also request a cost-share tiering or formulary exception. A request can also be made on behalf of the beneficiary by the beneficiary's appointed representative or the beneficiary's prescribing physician. Exception requests must include a statement written by your doctor. 
 
To request a coverage determination:

  • Complete our online form. You can also call, write, or fax us using the forms below. You, your doctor, or your representative can do this.

Our phone numbers are on the contact us page of this website, in the plan’s Evidence of Coverage (EOC), and on your ID card.

More information on requesting a coverage determination is provided in the plan’s EOC.

The timeframe for a coverage determination depends on the medical situation surrounding the request. A request for an expedited coverage determination can be made orally by calling us at 1-800-536-6167 (TTY/TDD: 711), 24 hours a day, 7 days a week.

 Medicare Prescription Drug Coverage Determination Forms:
(click on these forms to see the address and fax number to send written requests):


Appeal – Part D Drug - Coverage Redetermination

An appeal or "redetermination" is any of the procedures that deal with the review of an unfavorable coverage determination. You should file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

To request a coverage redetermination:

Complete our online form. You can also call, write, or fax us using the forms below. You, your doctor, or your representative can do this.

Our phone numbers are on the contact us page of this website, in the plan’s Evidence of Coverage (EOC), and on your ID card.

More information on requesting a coverage redetermination is in the plan’s EOC.

Forms to Request Appeal/Redetermination of Medicare Prescription Drug Denial:


You can also contact us to get the total number of grievances, appeals, and exceptions filed with us; to question processes; or to ask about the status of a previously submitted grievance, appeal or exception.
 


Other Resources to Help You

Medicare Rights Center:

Toll Free: 1 (888) HMO-9050


Elder Care Locator:

Toll Free: 1 (800) 677-1116


1-800-MEDICARE (1-800-633-4227)

TDD: 1 (877) 486-2048

24 hours a day, seven days a week

Medicare Complaint Form

Medicare Prescription Drug Determination Request Form

 

Page Last Updated: 03/21/2014
CMS Approved Date: Approved 02/08/2013
CMS Document ID: Y0022_PDPCCP_2013_4006_1202b

© Copyright 2008-2014 Coventry Health Care

Coventry Health Care is a Coordinated Care plan with a Medicare contract. First Health Part D is a Medicare-approved Part D sponsor. Enrollment in our plans depends on contract renewal.