Your Right to Make Complaints

You have the right to make a complaint if you have concerns or problems related to your coverage or care.  Appeals and grievances are the two different types of complaints you can make.

An appeal is the type of complaint you make when you want our plan to reconsider and change a decision we have made about the service or benefit that is covered or whether we will pay for it. 

A grievance is the type of complaint you make if you have any other type of problem with our plan or one of our plan providers. 

We will try to resolve any complaint that you might have and we will respond back to you as quickly as your case requires based on your health status.  If you have complaints about a denial of coverage or payment, you have the right to file an appeal within 60 calendar days after we notify you of the denial. 

If you have a complaint, want more detailed information on how to make complaints in different situations, want to file a standard or fast appeal, send us your grievance, or to get a summary of information about the grievances, appeals and exceptions that have been filed against our plans in the past:

• Refer to your Evidence of Coverage.
• Call Customer Service at the number located on the back of your ID card.
• Mail or fax us in writing: For the address or fax number refer to the back of the Evidence of Coverage booklet or click here for contact information.

 

Your Appeal Rights

For Prescription Drug Related Coverage

For more information about your appeal rights, see the Evidence of Coverage or call Customer Service at the number located on the back of your ID card or click on Contact Us.

There are two kinds of appeals you can request:

Expedited (72 hours) - You can request an expedited (fast) appeal for cases that involve prescription drug coverage if you or your doctor believes that your health could be seriously harmed by waiting up to 7 days for a decision.  If your request to expedite is granted, the independent reviewer must make a decision no later than 72 hours after receiving your appeal.

• If the doctor who prescribed the drug(s) asks for an expedited appeal for you, or supports you in asking for one, and the doctor indicates that waiting for 7 days could seriously harm your health, the independent reviewer will automatically expedite the appeal.
• If you ask for an expedited appeal without support from you doctor, the independent reviewer will decide if your health requires an expedited appeal.  If you do not get an expedited appeal, your appeal will be decided within 7 days.

Standard (7 days) - You can request a standard appeal for a case that involves coverage or payment.  The independent reviewer must give you a decision no later than 7 days after receiving your appeal. 

What Happens Next?

If you appeal, the independent reviewer will review our decision.  If any of the prescription drugs you requested are still denied, you can appeal to an administrative law judge (ALJ) if the value of your appeal meets a minimum dollar amount.  If you disagree with the ALJ decision, you will have the right to further appeal.  You will be notified of your appeal rights if this happens. 

For Non Prescription Drug Related Coverage

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 click on Contact Us.

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.

• If your doctor asks for an expedited appeal for you, or supports you in asking for one and the doctor the doctor indicates that waiting for 30 days could seriously harm your health, we will automatically expedite the appeal.
• If you ask for an expedited appeal without support from a doctor, we will decide if your health requires an expedited appeal.  If you do not get an expedited appeal, your appeal will be decided within 30 days. 

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?

For an Expedited Appeal: You or your appointed representative should contact us by telephone.

For a Standard Appeal: You or your appointed representative should mail your written appeal.

Call Customer Service at the number located on the back of your ID card, refer to the Evidence of Coverage booklet, or click on Contact Us.  If it is after hours, an appeals coordinator will be notified to contact you directly.

What Happens Next?

If we turn down your request, we are required to send your request to an independent review organization that has a contract with the federal government and is not a part of our plan.  This organization will review your request and make a decision about whether we must give you the care or payment you want.

If you are unhappy with the decision by the independent review organization that reviewed your case, you can appeal to an administrative law judge (ALJ) if the value of your appeal meets a minimum dollar amount.  If you disagree with the ALJ decision, you will have the right to further appeal.  You will be notified of your appeal rights if this happens. 

 

Part D Coverage Determinations and Exceptions

Exception - Coverage Determination

Whenever you ask for a Part D prescription drug benefit, the first step is requesting a coverage determination.  When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug.  Coverage determinations include exception requests.  You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment.  If you request an exception, your doctor must provide a statement to support your request.  You must contact us if you would like to request a coverage determination by completing the form listed below.

If you are a member of AdvantraRx (PDP) Part D Stand-alone Medicare Prescription Drug plan, use the Coverage Determination Form below.

• Instructions For Completing The Form
• Request for Medicare Prescription Drug Coverage Determination Form

If you are a member of an HMO, PPO, POS or PFFS plan (except Summit Health Plans and Vista Healthplans, Inc.), use the Coverage Determination Form below and send your completed form to the following address:

MAPD Pharmacy Clinical Call Center
3721 TecPort Drive
P.O. Box 67103
Harrisburg, PA 17106-7103   

• Request for Medicare Prescription Drug Coverage Determination Form

If you are a member of Summit Health Plans or Vista Healthplans, Inc., use the appropriate Coverage Determination Form below.

• Summit Health Plans Request for Medicare Prescription Drug Coverage Determination Form
• Vista Healthplans Request for Medicare Prescription Drug Coverage Determination Form

Appeal - Coverage Redetermination

An appeal or "redetermination" is any of the procedures that deal with the review of an unfavorable coverage determination.  You would 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.  You must contact us if you would like to request a coverage redetermination by completing the form listed below. 

If you are a member of AdvantraRx (PDP) Part D Stand-alone Medicare Prescription Drug plan, use the Coverage Redetermination Form below.

• Request For Medicare Prescription Drug Coverage Redetermination

If you are a member of Advantra Freedom (PFFS), use the Coverage Redetermination Form below

• Request For Medicare Prescription Drug Coverage Redetermination

If you are a member of an HMO, PPO or POS plan use the Coverage Redetermination Form below

• Request for Medicare Prescription Drug Coverage Redetermination

Denial of Medicare Prescription Drug Coverage

If we deny your request, we will send you a written decision explaining the reason why your request was denied.  We may decide completely or only partly against you.  For example, if we deny your request for payment for a Part D drug that you have already received, we may say that we will pay nothing or only part of the amount your requested.  If a coverage determination does not give you all that you requested, you have the right to appeal the decision.  Refer to your Evidence of Coverage for additional information.

Prior Authorizations

Some drugs require prior authorization because our doctors feel that they should only be used after other agents have been tried first.  Others are drugs that have only been used for very limited medical problems.  In deciding what drugs to put on the Prior Authorization List, our committee of doctors and pharmacists consider the safety, effectiveness and cost of the drugs as well as the medical literature on the subject.  These forms are available for your provider's use and can be obtained by selecting the link below. 

• Prior Authorization and Exception Forms

Step Therapy

Step Therapy is a form of Prior Authorization based on previous pharmaceutical treatment.  Drugs designated as stepped therapy will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim.  The Prior Authorization and Exception Forms are available for your provider's use by selecting the link noted above. 

 

Contact Information

Click here for contact information

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