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Table Of Contents
What to do if you have complaints
WHAT IS A GRIEVANCE?
FOR QUALITY OF CARE COMPLAINTS, YOU MAY ALSO
COMPLAIN TO THE QUALITY IMPROVEMENT ORGANIZATION (QIO)
WHAT IS A COVERAGE DETERMINATION?
WHAT IS AN APPEAL?
What to do if you have complaints
We encourage you to let us know right away if you have questions, concerns,
or problems related to your prescription drug coverage. Please call
our Customer Service at 1-800-688-1604 (TTY/TDD: 1-800-716-3231) 24
hours a day, 7 days a week (except Thanksgiving and Christmas). Calls
to these numbers are free.
Federal law guarantees your right to make
complaints if you have concerns or problems with any part of your care
as a plan member. The Medicare program has helped set the rules about
what you need to do to make a complaint, and what we are required to
do when someone makes a complaint. If you make a complaint, we must
be fair in how we handle it. You cannot be disenrolled from this Plan
or penalized in any way if you make a complaint.
A complaint will be handled as a grievance, coverage determination,
or an appeal, depending on the subject of the complaint. The following
section briefly discusses grievances, coverage determinations, and appeals.
WHAT IS A GRIEVANCE?
A grievance is any complaint other than one that involves a coverage
determination. You would file a grievance if you have any type of problem
with us or one of our network pharmacies that does not relate to coverage
for a prescription drug. For example, you would file a grievance if
you have a problem with things such as waiting times when you fill
a prescription, the way your network pharmacist or others behave, being
able to reach someone by phone or get the information you need, or
the cleanliness or condition of a network pharmacy.
HOW TO FILE A GRIEVANCE
A grievance usually will not involve coverage or payment for Part D prescription
drug benefits (concerns about our failure to cover or pay for a certain
drug should be addressed through the coverage determination process
discussed later).
What types of problems might lead to you filing a grievance?
- You feel that you are being encouraged to leave (disenroll from)
our Plan.
- Problems with the customer service you receive.
- Problems with how long you have to spend waiting on the phone or
in the pharmacy.
- Disrespectful or rude behavior by pharmacists or other staff.
- Cleanliness or condition of pharmacy.
- If you disagree with our decision not to expedite your request for
an expedited coverage determination or redetermination.
- You believe our notices and other written materials are difficult
to understand.
- Failure to give you a decision within the required timeframe.
- Failure to forward your case to the independent review entity if
we do not give you a decision within the required timeframe.
- Failure by the plan sponsor to provide required notices.
- Failure to provide required notices that comply with CMS standards.
In certain cases, you have the right to ask for a “fast grievance,” meaning
your grievance will be decided within 24 hours. We discuss these fast-track
grievances in more detail under ASKING FOR A
FAST DECISION.
If you have a grievance, we encourage you to first call Customer Service.
We will try to resolve any complaint that you might have over the phone.
If you request a written response to your phone complaint, we will respond
in writing to you. If we cannot resolve your complaint over the phone,
we have a formal procedure to review your complaints. We call this the
WPS Complaints and Grievances procedure. WPS Complaints and Grievances
addresses concerns about the service you have received. For example,
you may file a service grievance if you are dissatisfied about the way
a staff person has handled your particular issue or with the care you
received from your pharmacy.
You may file a service grievance by calling Customer Service at 1-800-688-1604
or by submitting a service complaint and grievance in writing to WPS
Health Insurance, c/o Medco Health Solutions, Inc., 8111 Royal Ridge
Parkway, Irving, TX 75063, ATTN: Medicare Administrative Review, or fax
it to 1-888-235-8551. Our normal business hours are from 7:00 a.m. to
8:00 p.m., central time, Monday through Friday. If you are requesting
a fast decision outside of normal business hours, be sure to call (not
fax) us at 1-800-753-2851 and listen to the recording for further directions.
Be sure to ask for a “fast,” "expedited," or “24-hour” review.
The Plan will contact you by phone to resolve your service grievance.
If your service grievance is not resolved in 5 days, you will receive
a written acknowledgement that your grievance has been received. If your
grievance involves a decision by our Appeals department to deny your
request to “expedite” a coverage determination or redetermination,
we will respond to you within 24 hours of receipt of your grievance,
provided that you have not already purchased the drug that is in dispute.
We must notify you of our decision about your grievance as quickly as
your case requires based on your health status, but no later than 30
calendar days after receiving your complaint. We may extend the timeframe
by up to 14 calendar days if you request the extension, or if we justify
a need for additional information and the delay is in your best interest.
FOR QUALITY OF CARE COMPLAINTS, YOU
MAY ALSO COMPLAIN TO THE QUALITY IMPROVEMENT ORGANIZATION (QIO)
Complaints concerning the quality of care received under Medicare may
be acted upon by the Medicare prescription drug plan under the grievance
process, by an independent organization called the QIO, or by both. For
example, if an enrollee believes his/her pharmacist provided the incorrect
dose of a prescription, the enrollee may file a complaint with the QIO
in addition to or in lieu of a complaint filed under the Part D plan's
grievance process. For any complaint filed with the QIO, the Part D plan
must cooperate with the QIO in resolving the complaint.
HOW TO FILE A QUALITY OF CARE COMPLAINT
WITH THE QIO
Quality of care complaints filed with the QIO must be made in writing.
An enrollee who files a quality of care grievance with a QIO is not required
to file the grievance within a specific time period. See the Introduction
for more information about how to file a quality of care complaint with
the QIO.
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 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 copayment. 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 (including an exception). You cannot request
an appeal if we have not issued a coverage determination.
HOW TO REQUEST A COVERAGE DETERMINATION
We use the word “provide” in a general way to include such
things as authorizing prescription drugs, paying for prescription drugs,
or continuing to provide a Part D prescription drug that you have been
getting.
If your doctor or pharmacist tells you that we will not cover
a prescription drug, you should contact us and ask for a coverage determination.
The following are examples of when you may want to ask us for a coverage
determination:
- If you are not getting a prescription drug that you believe may
be covered by us.
- If you have received a Part D prescription drug you believe may be
covered by us while you were a member, but we have refused to pay for
the drug.
- If we will not provide or pay for a Part D prescription drug that
your doctor has prescribed for you because it is not on our list of
covered drugs (called a “formulary”). You can request an
exception to our formulary.
- If you disagree with the amount that we require you to pay for a
Part D prescription drug that your doctor has prescribed for you. You
can request an exception to the copayment we require you to pay for
a drug.
- If you are being told that coverage for a Part D prescription drug
that you have been getting will be reduced or stopped.
- If there is a limit on the quantity (or dose) of the drug and you
disagree with the requirement or dosage limitation.
- If there is a requirement that you try another drug before we will
pay for the drug you are requesting.
- You bought a drug at a pharmacy that is not in our network and you
want to request reimbursement for the expense.
The process for requesting a coverage determination is discussed in
greater detail below in the section titled “Detailed information
about how to request a coverage determination and an appeal.”
WHO MAY ASK FOR A COVERAGE DETERMINATION?
You can ask us for a coverage determination yourself, or your prescribing
doctor or someone you name may do it for you. The person you name would
be your appointed representative. You can name a relative,
friend, advocate, doctor, or anyone else to act for you. Some other
persons may already be authorized under State law to act for you. If
you want someone to act for you, then you and that person must sign
and date a statement that gives the person legal permission to act
as your appointed representative. This statement must be sent to us
at WPS Health Insurance, c/o Medco Health Solutions, Inc., 8111 Royal
Ridge Parkway, Irving, TX 75063, ATTN: Medicare Administrative Review.
You can call Customer Service to learn how to name your appointed representative.
You
also have the right to have an attorney ask for a coverage determination
on your behalf. You can contact your own lawyer, or get the name of a
lawyer from your local bar association or other referral service. There
are also groups that will give you free legal services if you qualify.
You may use the forms shown below to request 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 copayment or you wish to
request a coverage determination. Just click on the forms and print
them out so you can complete the form and send it to us at the addresses
shown below.
DO YOU HAVE A REQUEST FOR A PART
D PRESCRIPTION DRUG THAT NEEDS TO BE DECIDED MORE QUICKLY THAN
THE STANDARD TIMEFRAME?
A decision about whether we will cover a Part D prescription drug can
be a “standard" coverage determination that is made within
the standard timeframe (typically within 72 hours; see below) or it can
be a “fast" coverage determination that is made more quickly
(typically within 24 hours; see below). A fast decision is sometimes
called an “expedited coverage determination.”
You can ask
for a fast decision only if you or your
doctor believes that waiting for a standard decision could seriously
harm your health or your ability to function. (Fast decisions apply only
to requests for Part D drugs that you have not received yet. You cannot
get a fast decision if you are requesting payment for a Part D drug that
you already received.)
ASKING FOR A STANDARD DECISION
To ask for a standard decision, you, your doctor, or your appointed representative
should refer to our Customer Service numbers listed on the cover and
in the Introduction section for assistance. Or, you can deliver a written
request to WPS Health Insurance, c/o Medco Health Solutions, Inc.,
8111 Royal Ridge Parkway, Irving, TX 75063, ATTN: Medicare Administrative
Review, or fax it to 1-888-235-8551.
Our normal business hours are from
7:00 a.m. to 8:00 p.m., central time, Monday through Friday. If you
are requesting a decision outside of normal business hours, be sure
to call (not fax) us at 1-800-753-2851, and listen to the recording
for further directions.
ASKING FOR A FAST DECISION
You, your doctor, or your appointed representative can ask us to give
a fast decision (rather than a standard decision) by calling our Customer
Service numbers listed on the cover and in the Introduction section.
Or, you can deliver a written request to WPS Health Insurance, c/o
Medco Health Solutions, Inc., 8111 Royal Ridge Parkway, Irving, TX
75063, ATTN: Medicare Administrative Review, or fax it to 1-888-235-8551.
Our normal business hours are from 7:00 a.m. to 8:00 p.m., central
time, Monday through Friday. If you are requesting a fast decision
outside of normal business hours, be sure to call (not fax) us at 1-800-753-2851
and listen to the recording for further directions. Be sure to ask
for a “fast,” "expedited," or “24-hour” review.
- If your doctor asks for a fast decision for you, or supports you
in asking for one, and the doctor indicates that waiting for a standard
decision could seriously harm your health or your ability to function,
we will automatically give you a fast decision.
- If you ask for a fast coverage determination without support from
a doctor, we will decide if your health requires a fast decision. If
we decide that your medical condition does not meet the requirements
for a fast coverage determination, we will send you a letter informing
you that if you get a doctor’s support for a fast review, we
will automatically give you a fast decision. The letter will also tell
you how to file a “grievance” if you disagree with our
decision to deny your request for a fast review. If we deny your request
for a fast coverage determination, we will give you our decision within
the 72-hour standard timeframe.
WHAT HAPPENS WHEN YOU REQUEST A COVERAGE
DETERMINATION?
What happens, including how soon we must decide, depends on the type
of decision.
- For a standard coverage determination about a Part D
drug, which includes a request about payment for a Part D drug
that you already received.
Generally, we must give you our decision no later than 72 hours after
we have received your request, but we will make it sooner if your health
condition requires. However, if your request involves a request for an
exception (including a formulary exception, tiering exception, or an
exception from utilization management rules – such as dosage or
quantity limits or step therapy requirements), we must make our decision
no later than 72 hours after we have received your doctor's “supporting
statement,” which explains why the drug you are asking for is medically
necessary. If you are requesting an exception, you should submit
your prescribing doctor's supporting statement with the request, if possible.
We will give you a decision in writing about the prescription drug you
have requested. You will get this notification when we make our decision
under the timeframe explained above. If we do not approve your request,
we must explain why, and tell you of your right to appeal our decision.
The section “Appeal Level 1” explains how to file this appeal.
If we have not given you an answer within 72 hours after receiving your
request, your request will automatically go to Appeal Level 2, where
an independent organization will review your case.
- For a fast coverage determination about a Part D drug that
you have not received.
If you get a fast review, we will give you our decision within 24 hours
after you or your doctor asks for a fast review—sooner if your
health requires. If your request involves a request for an exception,
we must make our decision no later than 24 hours after we get your doctor's "supporting
statement," which explains why the non-formulary or non-preferred
drug you are asking for is medically necessary.
We will give you a decision in writing about the prescription drug you
have requested. You will get this notification when we make our decision,
under the timeframe explained above. If we do not approve your request,
we must explain why, and tell you of your right to appeal our decision.
The section “Appeal Level 1” explains how to file this appeal.
If we decide you are eligible for a fast review, and we have not responded
to you within 24 hours after receiving your request, your request will
automatically go to Appeal Level 2, where an independent organization
will review your case.
If we do not grant your or your doctor's request for a fast review,
we will give you our decision within the standard 72-hour timeframe discussed
above. If we tell you about our decision not to provide a fast review
by phone, we will send you a letter explaining our decision within three
calendar days after we call you. The letter will also tell you how to
file a “grievance” if you disagree with our decision to deny
your request for a fast review, and will explain that we will automatically
give you a fast decision if you get a doctor’s support for a fast
review.
WHAT HAPPENS IF WE DECIDE COMPLETELY
IN YOUR FAVOR?
If we make a coverage determination that is completely in your favor,
what happens next depends on the situation.
- For a standard decision about a Part D drug, which includes
a request about payment for a Part D drug that you already received.
We must authorize or provide the benefit you have requested as quickly
as your health requires, but no later than 72 hours after we received
the request. If your request involves a request for an exception, we
must authorize or provide the benefit no later than 72 hours after we
get your doctor’s “supporting statement.” If you are
requesting reimbursement for a drug that you already paid for and received,
we must send payment to you no later than 30 calendar days after we get
the request.
- For a fast decision about a Part D drug that you have not received.
We must authorize or provide you with the benefit you have requested
no later than 24 hours of receiving your request. If your request involves
a request for an exception, we must authorize or provide the benefit
no later than 24 hours after we get your doctor's “supporting statement.”
WHAT HAPPENS IF WE DENY YOUR REQUEST?
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 you requested.
If a coverage determination does not give you all that you
requested, you have the right to appeal the decision.
WHAT IS AN APPEAL?
An appeal 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.
WHAT KINDS OF DECISIONS CAN BE APPEALED?
You can generally appeal our decision not to cover a drug, vaccine, or
other Part D benefit. You may also appeal our decision not to reimburse
you for a Part D drug that you paid for. You can also appeal if you
think we should have reimbursed you more than you received or if you
are asked to pay a different cost-sharing amount than you think you
are required to pay for a prescription. Finally, if we deny your exception
request, you can appeal. A coverage determination, which includes those
described in the section titled “Detailed information about how
to request a coverage determination and appeal,” may be appealed
if you disagree with our decision.
Note: If we approve your exception request for a non-formulary drug,
you cannot request an exception to the copayment we require you to pay
for the drug.
WHO MAY FILE YOUR APPEAL OF THE COVERAGE
DETERMINATION?
The rules about who may file an appeal are almost the same as the rules
about who may ask for a coverage determination. For a standard request,
you or your appointed representative may file the request. A fast appeal
may be filed by you, your appointed representative, or your prescribing
doctor.
HOW SOON MUST YOU FILE YOUR APPEAL?
You need to file your appeal within 60 calendar days from the date included
on the notice of our
coverage determination. We can give you more time if you have a good
reason for missing the deadline.
To file a standard appeal, you can send
the appeal to us in writing at
WPS Health Insurance, c/o Medco Health Solutions, Inc., 8111 Royal Ridge
Parkway, Irving, TX 75063, ATTN: Medicare Clinical Appeals.
HOW DOES THE APPEALS PROCESS WORK?
There are five levels to the appeals process. Here are a few things to
keep in mind as you read the description of these steps in the appeals
process:
- Moving from one level to the next. At each level,
your request for Part D benefits or payment is considered and a decision
is made. The decision may be partly or completely in your favor (giving
you some or all of what you have asked for), or it may be completely
denied (turned down). If you are unhappy with the decision, there
may be another step you can take to get further review of your request.
Whether you are able to take the next step may depend on the dollar
value of the requested drug or on other factors.
- Who makes the decision at each level? You make your
request for coverage or payment of a Part D prescription drug directly
to us. We review this request and make a coverage determination. If
our coverage determination is to deny your request (in whole or in
part), you can go on to the first level of appeal by asking us to review
our coverage determination. If you are still dissatisfied with the
outcome, you can ask for further review. If you ask for further review,
your appeal is then sent outside of this Plan, where people who are
not connected to us conduct the review and make the decision. After
the first level of appeal, all subsequent levels of appeal will be
decided by someone who is connected to the Medicare program or the
Federal court system. This will help ensure a fair, impartial decision.
Each
appeal level is discussed in greater detail below in the section titled “Detailed
information about how to request a coverage determination and an appeal.”
Appeal Level 1: Asking
us to reconsider our coverage determination.
Please call Customer Service if you need help with filing your appeal.
You may ask us to reconsider our coverage determination, even if only
part of our decision is not what you requested. When we get your request
to reconsider the coverage determination, we give the request to people
at our organization who were not involved in making the coverage determination.
This helps ensure that we will give your request a fresh look.
How you make your appeal depends on whether you are requesting reimbursement
for a Part D drug you already received and paid for, or authorization
of a Part D benefit (that is, a Part D drug that you have not yet received).
If your appeal concerns a decision we made about authorizing a Part D
benefit that you have not received yet, then you and/or your doctor will
first need to decide whether you need a fast appeal. The procedures for
deciding on a standard or a fast appeal are the same as those
described for a standard or fast coverage determination. Please
see the discussion under “Do you have a request for a Part D prescription
drug that needs to be decided more quickly than the standard timeframe?” and “Asking
for a fast decision.”
GETTING INFORMATION TO SUPPORT YOUR
APPEAL
We must gather all the information we need to make a decision about your
appeal. If we need your assistance in gathering this information, we
will contact you. You have the right to get and include additional information
as part of your appeal. For example, you may already have documents related
to your request, or you may want to get your doctor’s records or
opinion to help support your request. You may need to give the doctor
a written request to get information.
You can give us your additional information in any of the following
ways:
- In writing: WPS Health Insurance, c/o Medco Health Solutions, Inc.,
8111 Royal Ridge Parkway, Irving, TX 75063, ATTN: Medicare Clinical
Appeals.
- By fax, at 1-888-235-8551.
- By telephone—if it is a fast appeal—at 1-800-753-2851.
- In person, at WPS Health Insurance, 1751 W. Broadway, Madison, Wisconsin.
You also have the right to ask us for a copy of information regarding
your appeal. You can call 1-800-753-2851 or write us at WPS Health Insurance,
c/o Medco Health Solutions, Inc., 8111 Royal Ridge Parkway, Irving, TX
75063, ATTN: Medicare Clinical Appeals.
WHAT IF YOU WANT A FAST APPEAL?
The rules about asking for a fast appeal are the same as the rules about
asking for a fast coverage determination. You, your doctor, or your
appointed representative can ask us to give a fast appeal (rather than
a standard appeal) by calling our Customer Service numbers listed on
the cover and in the Introduction section. Or you can deliver a written
request to WPS Health Insurance, c/o Medco Health Solutions, Inc.,
8111 Royal Ridge Parkway, Irving, TX 75063, ATTN: Medicare Clinical
Appeals, or fax it to 1-888-235-8551. Our normal business hours are
from 7:00 a.m. to 8:00 p.m. central time, Monday through Friday. If
you are requesting a fast decision outside of normal business hours,
be sure to call (not fax) us at 1-800-753-2851 and listen to the recording
for further directions. Be sure to ask for a “fast,” “expedited,” or “72-hour” review.
Remember, that if your prescribing doctor provides a written or oral
supporting statement explaining that you need the fast appeal, we will
automatically treat you as eligible for a fast appeal.
HOW SOON MUST WE DECIDE ON YOUR APPEAL?
How quickly we decide on your appeal depends on the type of appeal:
- For a standard decision about a Part D drug, which
includes a request for reimbursement for a Part D drug you already
paid for and received.
After we get your appeal, we have up to 7 calendar days to give you
a decision but will make it sooner if your health condition requires
us to. If we do not give you our decision within 7 calendar days, your
request will automatically go to the second level of appeal,
where an independent organization will review your case.
- For a fast decision about a Part D drug that you have not
received.
After we get your appeal, we have up to 72 hours to give you a decision,
but will make it sooner if your health requires us to. If we do not give
you our decision within 72 hours, your request will automatically go
to Appeal Level 2, where an independent organization will review your
case.
WHAT HAPPENS NEXT IF WE DECIDE COMPLETELY
IN YOUR FAVOR?
- For a decision about reimbursement for a Part D drug you
already paid for and received.
We must send payment to you no later than 30 calendar days after we
get your request to reconsider our coverage determination.
- For a standard decision about a Part D drug you have
not received.
We must authorize or provide you with the Part D drug you have asked
for as quickly as your health requires, but no later than 7 calendar
days after we get your appeal.
- For a fast decision about a Part D drug you have not received.
We must authorize or provide you with the Part D drug you have asked
for within 72 hours of receiving your appeal or sooner, if your health
would be affected by waiting this long.
WHAT HAPPENS NEXT IF WE DENY YOUR
APPEAL?
If we deny any part of your appeal, you or your appointed representative
has the right to ask an independent organization to review your case.
This IRE contracts with the Federal government and is not part of our
Plan.
Appeal Level 2: If we
deny any part of your first appeal, you may ask for a review by a government-contracted
independent review entity (IRE).
WHAT IRE DOES THIS REVIEW?
At the second level of appeal, your appeal is reviewed by an outside,
IRE that has a contract with the Centers for Medicare & Medicaid
Services (CMS), the government agency that runs the Medicare program.
The IRE has no connection to us. You have the right to ask us for a
copy of your case file that we sent to this organization.
HOW SOON MUST YOU FILE YOUR APPEAL?
You or your appointed representative must make a request for review by
the IRE in writing within 60 calendar days after the date you
were notified of the decision on your first appeal. You must send your
written request to the IRE whose name and address are included in the
redetermination notice you get from us.
WHAT IF YOU WANT A FAST APPEAL?
The rules about asking for a fast appeal are the same as the rules about
asking for a fast coverage determination, except your prescribing doctor
cannot file the request for you—only you or your appointed representative
may file the request. If you want to ask for a fast appeal, please
follow the instructions under “Asking for a fast decision.” Remember
that if your prescribing doctor provides a written or oral supporting
statement explaining that you need the fast appeal, the IRE will automatically
treat you as eligible for a fast appeal.
HOW SOON MUST THE INDEPENDENT REVIEW
ENTITY DECIDE?
After the IRE gets your appeal, how long the organization can take to
make a decision depends on the type of appeal:
- For a standard request about a Part D drug, which includes
a request about reimbursement for a Part D drug that you already
paid for and received, the IRE has up to 7 calendar days from the
date it gets your request to give you a decision.
- For a fast decision about a Part D drug that you have not
received, the IRE has up to 72 hours from the time it gets the
request to give you a decision.
IF THE INDEPENDENT REVIEW ENTITY
DECIDES COMPLETELY IN YOUR FAVOR:
The IRE will tell you in writing about its decision and the reasons for
it. What happens next depends on the type of appeal:
- For a decision about reimbursement for a Part D drug you
already paid for and received.
We must pay within 30 calendar days from the date we get notice reversing
our coverage determination. We will also send the IRE a notice that we
have abided by their decision.
- For a standard decision about a Part D drug you have
not received.
We must authorize or provide you with the Part D drug you have asked
for within 72 hours from the date we get notice reversing our coverage
determination. We will also send the IRE a notice that we have abided
by their decision.
- For a fast decision about a Part D drug you have not received.
We must authorize or provide you with the Part D drug you have asked
for within 24 hours from the date we get notice reversing our coverage
determination. We will also send the IRE a notice that we have abided
by their decision.
WHAT HAPPENS NEXT IF THE REVIEW ORGANIZATION
DECIDES AGAINST YOU (EITHER PARTLY OR COMPLETELY)?
The IRE will tell you in writing about its decision and the reasons for
it. You or your appointed representative may continue your appeal by
asking for a review by an ALJ (see Appeal Level 3), provided that the
dollar value of the contested Part D benefit is $130 or more.
Appeal Level 3: If the
organization that reviews your case in Appeal Level 2 does not rule
completely in your favor, you may ask for a review by an ALJ (ALJ).
As stated above, if the IRE does not rule completely in your favor, you
or your appointed representative may ask for a review by an ALJ. You
must make a request for review by an ALJ in writing within 60
calendar days after the date of the decision made at Appeal Level 2.
You may request that the ALJ extend this deadline for good cause. You
must send your written request to:
Office of Medicare Hearings and Appeals
Cleveland, Ohio (Mid-West Field Office)
BP Tower, Suite 1300,
200 Public Square,
Cleveland, OH 44114-2316
Phone: 866-236-5089
You, or your representative (if any), must file written requests for an ALJ hearing within 60 days from receipt of the Notice of Reconsideration from the IRE. Again, the appeal must be above $130 (in Fiscal Year 2006) in order for the ALJ to hear the case. Information on how to file an appeal is contained in the Notice of Reconsideration that you have received from the IRE. The address for the correct field office is also contained in that Notice. Addresses and contact information for all of the Office of Medicare Hearings and Appeals field offices can also be found at http://www.hhs.gov/omha/offices.html.
You, your chosen representative (if any), and the local agency will
receive written notice of the scheduled time, date, and place of the
hearing at least 10 days before the fair hearing. The hearing will be
held in the county where you live.
During the ALJ review, you may present evidence, review the record (by
either receiving a copy of the file or getting the file in person when
feasible), and be represented by counsel. The ALJ will not review your
appeal if the dollar value of the requested Part D benefit is less than
$130. If the dollar value is less than $130, you may not appeal any further.
HOW IS THE DOLLAR VALUE (THE “AMOUNT
REMAINING IN CONTROVERSY”) CALCULATED?
If we have refused to provide Part D prescription drug benefits, the
dollar value for requesting an ALJ hearing is based on the projected
value of those benefits. The projected value includes any costs you could
incur based on the number of refills prescribed for the requested drug
during the plan year. Projected value includes your copayments, all
costs incurred after your costs exceed the initial coverage limit, and
costs paid by other entities.
You may also combine multiple Part D claims to meet the dollar value
if:
- The claims involve the delivery of Part D prescription drugs to
you;
- All of the claims have received a determination by the IRE as described
in Appeal Level 2;
- Each of the combined requests for review are filed in writing within
60 calendar days after the date that each decision was made at Appeal
Level 2; and
- Your hearing request identifies all of the claims to be heard by
the ALJ.
HOW SOON DOES THE JUDGE MAKE A DECISION?
The ALJ will hear your case, weigh all of the evidence up to this point,
and make a decision as soon as possible.
IF THE JUDGE DECIDES IN YOUR FAVOR:
The ALJ will tell you in writing about his or her decision and the reasons
for it. What happens next depends on the type of appeal:
- For a decision about payment for a Part D drug you already
received.
We must send payment to you no later than 30 calendar days from the
date we get notice reversing our coverage determination.
- For a standard decision about a Part D drug you have
not received.
We must authorize or provide you with the Part D drug you have asked
for within 72 hours from the date we get notice reversing our coverage
determination.
- For a fast decision about a Part D drug you have not received.
We must authorize or provide you with the Part D drug you have asked
for within 24 hours from the date we get notice reversing our coverage
determination.
IF THE JUDGE RULES AGAINST YOU:
You have the right to appeal this decision by asking for a review by
the MAC (Appeal Level 4). The letter you get from the ALJ will tell
you how to request this review.
Appeal Level 4: Your
case may be reviewed by the MAC (MAC).
The MAC will first decide whether to review your case. There is no minimum
dollar value for the MAC to hear your case. If you got a denial at Appeal
Level 3, you or your appointed representative can request review by filing
a written request with the Council.
The MAC does not review every case. When it gets your case, it will
first decide whether to review your case. If they decide not to review
your case, then you may request a review by a Federal Court Judge (see
Appeal Level 5). The MAC will issue a written notice advising you of
any action taken with respect to your request for review. The notice
will tell you how to request a review by a Federal Court Judge.
HOW SOON WILL THE COUNCIL MAKE A
DECISION?
If the MAC reviews your case, they will make
their decision as soon as possible.
IF THE COUNCIL DECIDES IN YOUR FAVOR:
The MAC will tell you in writing about its decision and the reasons for
it. What happens next depends on the type of appeal:
- For a decision about payment for a Part D drug you already
received.
We must send payment to you no later than 30 calendar days from the
date we get notice reversing our coverage determination.
- For a standard decision about a Part D drug you have
not received.
We must authorize or provide you with the Part D drug you have asked
for within 72 hours from the date we get notice reversing our coverage
determination.
- For a fast decision about a Part D drug you have not received.
We must authorize or provide you with the Part D drug you have asked
for within 24 hours from the date we get notice reversing our coverage
determination.
IF THE COUNCIL DECIDES AGAINST YOU:
If the amount involved is $1,260 or more, you have the right to continue
your appeal by asking a Federal Court Judge to review the case (Appeal
Level 5). The letter you get from the Medicare Appeals Council will
tell you how to request this review. If the value is less than $1,260,
the Council’s decision is final and you may not take the appeal
any further.
Appeal Level 5: Your
case may go to a Federal Court
In order to request judicial review of your case, you must file a civil
action in a United States district court. The letter you get from the
MAC in Appeal Level 4 will tell you how to request this review. The Federal
Court Judge will first decide whether to review your case.
If the contested amount is $1,260 or more, you may ask a Federal Court
Judge to review the case.
HOW SOON WILL THE JUDGE MAKE A DECISION?
The Federal judiciary is in control of the timing of any decision.
IF THE JUDGE DECIDES IN YOUR FAVOR:
Once we get notice of a judicial decision in your favor, what happens
next depends on the type of appeal:
- For a decision about payment for a Part D drug you already
received.
We must send payment to you within 30 calendar days from the date we
get notice reversing our coverage determination.
- For a standard decision about a Part D drug you have
not received.
We must authorize or provide you with the Part D drug you have asked
for within 72 hours from the date we get notice reversing our coverage
determination.
- For a fast decision about a Part D drug you have not received.
We must authorize or provide you with the Part D drug you have asked
for within 24 hours from the date we get notice reversing our coverage
determination.
IF THE JUDGE DECIDES AGAINST YOU:
The Judge’s decision is final and you may not take the appeal any
further.
You can contact us if you need additional information regarding the
number of appeals and grievances filed by our members. Please call 1-800-731-0459
(1-888-877-2837 TTY/TDD), 8 am – 8 pm, 7 days a week. |
