A Healthy CollaborationSM

Exceptions, Appeals and Grievances for Medical Coverage

Find out more about the Exceptions and Appeals processes.

The following procedures for Exceptions, Appeals and Grievances are endorsed by the Centers for Medicare and Medicaid and must be followed by the plan in identifying, tracking, resolving, and reporting all activity related to exceptions, appeals, or grievances.

Member Exceptions Process

What is a Coverage Determination?

Whenever you ask for a Part D prescription drug benefit, the first step is called 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 exceptions 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), believe you should get a drug at a lower co-payment, or request a waiver on coverage restrictions or limits on your drug.

Who Can File a Coverage Determination?

You can ask us for a coverage determination yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your authorized representative. If you want someone to act for you, then you and this person must sign and date an authorized representative form that gives this person legal permission to act as your authorized representative. Please return this form to:

4888 Loop Central Drive, Suite 700,
Houston, Texas 77081.

If you have questions about how to name an authorized representative, please contact Member Services.

When Can a Coverage Determination Be Requested?

You can request a coverage determination in the following situations:

  • A drug is not on your plan’s list of covered drugs
  • An exception to your plan’s utilization management tools (dosage limits, quantity limits, or step therapy requirements)
  • A non-preferred Part D drug be considered at the preferred cost-sharing level
  • A drug requires prior authorization prior to being covered at the pharmacy

Asking for a “Standard” or “Fast” Coverage Determination

A decision about whether we will cover a Part D prescription drug can be a “standard coverage determination” that is made within the standard time frame (typically within 72 hours) or it can be a “fast” coverage determination that is made more quickly (typically within 24 hours). You can ask for a fast coverage determination only if you or your doctor believe that waiting for a standard coverage determination could seriously harm your health or your ability to function (this does not apply if you are requesting a payment for a Part D drug that you already received).

How to Request a Coverage Determination

You, your physician, or your authorized representative can call Member Services to initiate the coverage determination process or you can have your physician complete Medicare’s Coverage Determination Request Form and mail it to:

MemberHealth – Claims Processing
P.O. Box 39668
Solon, OH 44139-3966

For more detailed information related to coverage determinations and/or exceptions, please refer to sections 6 and 11 of your Evidence of Coverage.

Member Appeals

Who can file an Appeal?

An appeal may be filed by any of the following:

  • A member, including the member’s authorized representative,
  • A member’s physician, an ancillary provider or a hospital representing the member, or
  • A legal representative of the deceased’s estate.

What is an Appeal?

An appeal is a request from a member to the health plan to reconsider a decision, also called an organizational determination. An appeal is the start of a process in response to a decision made by the health plan to:

  • Discontinue or reduce services, or
  • Pay or not to pay for services, that a member believes should be furnished.

When can an Appeal be filed?

A member has sixty (60) days to file an appeal regarding medical care:

  • That has not been approved,
  • That is being discontinued or reduced, or
  • That would pay or not pay for services already furnished.

An appeal may be received verbally or in writing.

Where can an appeal be filed?

An appeal may be filed with any of the following organizations:

  • Centers for Medicare and Medicaid Services (CMS),
  • The Social Security Administration (SSA),
  • The Railroad Bureau (RRB), and
  • The Health Plan.

All employees and affiliates of a health plan are required to know where to direct member appeals.

Why file an appeal?

A member may file an appeal when an adverse decision is made that they want overturned, as well as to protect their rights.

Fast Decisions / Expedited Appeals

A member may request a decision be decided more quickly. The health plan must first determine if the appeal meets the following criteria for expedited appeals:

  • If the standard process and timeliness could jeopardize the life of health of the member, or
  • The likelihood of member’s ability to regain maximum function is reduced.

M0018_H8742webr4_1208_CMS (1/2009) Last updated: 1/1/2022

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