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, but no later than 30 calendar days after the date we receive the complaint.  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 your Evidence of Coverage booklet or contact us.

 

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 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, we 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, we will automatically expedite the appeal.
• If you ask for an expedited appeal without support from you 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 7 days.

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

What Happens Next?

Expedited (72 hours) –

• Decision is in your favor:  We must provide the coverage we have agreed to provide within 72 hours after we receive your appeal.
• Decision is not in your favor:  We will send you a written statement that explains why we said no and how to appeal our decision.

Standard (7 days) –

• Decision is in your favor:  We must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal. Or, in cases where we have approved a request to pay you back for a drug you already bought, we must send payment to you within 30 calendar days after we receive your appeal request.
• Decision is not in your favor:  If we do not decide in your favor, we will send you a written statement that explains why we said no and how to appeal our decision.

Further Appeals:

If we say no to your appeal, you then can choose whether to accept our decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, an Independent Review Organization, that has a contract with the federal government and is not part of our plan, reviews the decision our plan made when we said no to your first appeal. This organization decides whether the decision we made should be changed. If after the Independent Review Organization’s review, they decide to still disapprove your appeal, 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 Medical Care 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 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 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 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.  A request can also be made on behalf of the beneficiary by the beneficiary’s appointed representative or the beneficiary’s prescribing physician.

A request for a standard coverage determination can be made in writing and faxed to (800) 639-9158 or mailed to
Coventry Health Care / First Health Part D
Coverage Determinations
P.O. Box 7773
London, KY 40742

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

• Request For Medicare Prescription Drug Coverage Redetermination

If you are a member of an HMO, PPO or POS plan use the Coverage Determination Form found on your plan's Prescription Drug Forms page:

• Arkansas
• Florida
• Georgia
• Illinois - Central & Northern
• Illinois - Southwest
• Iowa
• Kansas
• Missouri - Eastern
• Missouri - Western
• Nebraska
• North Carolina
• Ohio - Northeast
• Pennsylvania
• South Dakota
• Texas
• Utah
• Wyoming

A request for an expedited coverage determination can be made by calling (800) 551-2694 or TTY 711 Telecommunications Relay Service for the hearing or speech impaired or in writing via fax to (800) 639-9158.

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.  Once you have completed the form, please mail or fax it along with any supporting documentation to your plan at the address or fax number indicated on the form or contact the Appeals & Grievances department for your plan.

You can also use this contact information to obtain an aggregate number of grievances, appeals, and exceptions filed, to question processes or inquire as to status of previously submitted grievances, appeals or exceptions.

If you are a member of First Health Part D (PDP) 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 an HMO, PPO or POS plan use the Coverage Redetermination Form found on your plan's Prescription Drug Forms page:

• Arkansas
• Florida
• Georgia
• Illinois - Central & Northern
• Illinois - Southwest
• Iowa
• Kansas
• Missouri - Eastern
• Missouri - Western
• Nebraska
• North Carolina
• Ohio - Northeast
• Pennsylvania
• South Dakota
• Texas
• Utah
• Wyoming
  A request for an expedited coverage redetermination can be made by calling (800)-536-6767 or TTY 711 Telecommunications Relay Service for the hearing or speech impaired or in writing via fax to (800) 535-4047.

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.  If you are a member of First Health Part D (PDP), refer to Chapter 7 in your Evidence of Coverage for additional information.  If you are a member of a Medicare Advantage (MA) or a Medicare Advantage Prescription Drug (MAPD) plan, refer to Chapter 7 (MA plans) or Chapter 9 (MAPD plans) in your Evidence of Coverage for additional information.  Select your plan and locate your Evidence of Coverage.

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

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Appointment of Representative

You, your prescribing physician, or someone you name may communicate with us on your behalf  to request an initial determination or file a grievance or appeal. The person you name would be your “appointed representative.” You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under State law to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives 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

Disclaimers

Coventry Health Care is a Coordinated Care plan with a Medicare contract. A Medicare-approved Part D sponsor.

Coventry Health Care of Florida, Missouri, Kansas and Pennsylvania (HealthAmerica) also have contracts with the Florida, Missouri, Kansas and Missouri, and Pennsylvania state Medicaid programs (respectively).

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, premium and/or co-payments/co-insurance may change on January 1 of each year.

Plan performance Star Ratings are assessed each year and may change from one year to the next.

Our dual-eligible Special Needs Plans (DSNPs) are available in Florida, Missouri, Kansas and Pennsylvania to anyone who has both Medical Assistance from the state and Medicare. Premiums, copays, coinsurance and deductibles may vary based on the level of Extra Help that you receive. Please contact the plan for further details.

You must continue to pay your Medicare Part B premium. The Part B premium is covered for full-dual members where DSNP plans are available.

This information is available for free in other languages. Please contact First Health Part D customer service at 1-855-739-9726 (TTY/TDD 711) or Coventry Health Care customer service (for Medicare Advantage plans), 1-877-988-3589, 8 a.m. to 8 p.m., seven days, from October 1 – February 14; 8 a.m. to 8 p.m. Monday – Friday, from February 15 – September 30.

Medicare beneficiaries may also enroll through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.