Medicare Part D grievance and appeals guide

              Medicare Part D
Grievance and Appeals Guide
HealthChoice Employer PDP
High and Low Option Medicare
Supplement Plans With Part D
MDIS #2452
E7848_F7000
Oklahoma State and Education Employees Group Insurance BoardTable of Contents
Who to Contact About a Grievance or Appeal.................................................................1
What to do if you Have a Problem or Concern................................................................2
Introduction and Overview of the Grievance and Appeal Processes.........................2
Filing a Grievance......................................................................................................2
Asking for a Coverage Decision.................................................................................3
Asking for a Prior Authorization/Exception...............................................................3
Asking for an Appeal.................................................................................................3
If you Need Help During any Part of the Grievance or Appeal Processes....................4
HIPAA Authorization to Disclose Health Information..............................................4
Filing a Grievance...............................................................................................................5
Asking for a Fast Decision..........................................................................................5
Reasons to File a Grievance........................................................................................6
Filing a Grievance/ with the Quality Improvement Organization..............................7
Asking for a Coverage Decision..........................................................................................8
Asking for a Prior Authorization/Exception.....................................................................8
Prior Authorization/Exception for a Covered Drug...................................................8
Prior Authorization/Exception to the Plan’s Quantity Limitation Rules...................8
Prior Authorization/Exception for a Non-Formulary or Non-Covered Drug............9
Prior Authorization/Exception for a Tier Exception to Receive a Lower Copay......9
Prior Authorization/Exception to the Step Therapy Process....................................10
Asking for a Standard Decision.................................................................................10
Asking for a Fast Decision........................................................................................10
Asking HealthChoice to Pay you Back for a Drug You Already Purchased.............12
If Your Request is Approved....................................................................................12
If Your Request is Denied.........................................................................................12
Asking for a Level 1 Appeal............................................................................................13
Asking for a Standard Appeal...................................................................................13
Asking for a Fast Appeal...........................................................................................14
If Your Level 1 Appeal is Denied.............................................................................14
Asking for a Level 2 Appeal............................................................................................15
Asking for a Standard Appeal...................................................................................15
Asking for a Fast Appeal...........................................................................................16
If Your Level 2 Appeal is Denied.............................................................................16
Level 3, 4, and 5 Appeals.................................................................................................17
Asking for a Level 3 Appeal.....................................................................................17
Asking for a Level 4 Appeal.....................................................................................17
Asking for a Level 5 Appeal.....................................................................................18
Flow Chart for Medicare Part D Appeal Processes.......................................................19
1Who to Contact About
a Grievance or Appeal
Prior Authorization/Exception
Medco
24 hours a day/7 days a week
Toll-free 1-800-753-2851 or toll-free TDD 1-800-825-1230
Pharmacy Appeals (Level 1 Appeals)
HealthChoice Member Services - Ask for the Pharmacy Unit
Monday through Friday, 7:30 a.m. to 4:30 p.m. Central time
1-405-717-8699 or toll-free 1-800-865-5142, Fax 1-405-717-8925
TDD 1-405-949-2281 or toll-free 1-866-447-0436
HealthChoice, Attention Pharmacy Unit
3545 NW 58th Street, Suite 110
Oklahoma City, OK 73112
Pharmacy Grievances
HealthChoice Member Services
Monday through Friday, 7:30 a.m. to 4:30 p.m. Central time
1-405-717-8699 or toll-free 1-800-865-5142, Fax 1-405-717-8942
TDD 1-405-949-2281 or toll-free 1-866-447-0436
HealthChoice, Attention Medicare Grievances
3545 NW 58th Street, Suite 110
Oklahoma City, Oklahoma 73112
Quality Improvement Organization
Oklahoma Foundation for Medical Quality
Monday through Thursday, 8:00 a.m. to 4:30 p.m. Central time
14000 Quail Springs Parkway, Suite 400
Oklahoma City, Oklahoma, 73134
Toll-free 1-800-522-3414 or for the hearing impaired, please use relay service
Fraud, Waste, and Abuse Reporting
Health Integrity, LLC
Monday through Friday, 8:00 a.m. to 7:00 p.m. Eastern time
Toll-free 1-877-772-3379 or TDD 1-800-855-2880
Email: MEDICinfo@healthintegrity.org
1What to do if you Have a Problem or Concern
Introduction and Overview
of the Grievance and Appeal Processes
This Guide is intended to provide the information you need if you have a problem or concern about your Medicare Part D prescription drug coverage. The Medicare program has set rules about what you need to do to voice a problem or concern, as well as what HealthChoice is required to do when it learns about your problem.
Please let HealthChoice know right away if you have questions, problems, or concerns related to your Medicare Part D prescription drug coverage. HealthChoice Member Services will work with you to try to find a satisfactory solution to your problem. Contact HealthChoice Member Services at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
As a member of Medicare and this Plan, you have certain rights. HealthChoice staff members have pledged to honor your rights, take your problems and concerns seriously, and treat you with respect. HealthChoice must always treat you fairly when handling your issue. You cannot be disenrolled or penalized in any way for voicing a problem or concern. If at any time during the grievance and/or appeals process you feel you need additional help or information, please don’t hesitate to contact HealthChoice Member Services at the numbers listed above.
There are two processes for handling problems related to your Medicare Part D prescription drug coverage. One process must be followed when you file a grievance, and a different process must be followed when you ask for a coverage decision, including a prior authorization/exception or an appeal. First, you need to know what the phrases filing a grievance, asking for a coverage decision, asking for a prior authorization/exception, and asking for an appeal mean to you as a member of a Medicare Part D plan.
Filing a Grievance
You can file a grievance if you have a problem or concern about waiting times, customer service, or getting accurate and timely information from HealthChoice or its pharmacy benefits manager, Medco. You can also file a grievance if you have a concern with the quality of care you received. A grievance does not involve coverage or payment for your prescription drugs.
Please let HealthChoice know right away if you have a problem or concern about your Medicare Part D prescription drug coverage. The Plan will work with you to try to find a solution to your problem.
2Asking for a Coverage Decision
HealthChoice makes a coverage decision each time you ask the Plan to cover or pay for your prescription drugs. HealthChoice makes a coverage decision each time you:
• Request a prescription from your pharmacy or other provider
• Ask for a prior authorization/exception
• Ask HealthChoice to pay you back for a drug you already purchased
• Ask for an appeal
If you disagree with the Plan’s decision, you can file an appeal. See Asking for a Level 1 Appeal section.
Asking for a Prior Authorization/Exception
When you ask for a prior authorization/exception, you are asking HealthChoice to make a coverage decision and change its pharmacy benefit rules or restrictions. If you disagree with the Plan’s decision, you can file an appeal. See Asking for a Level 1 Appeal section.
Asking for an Appeal
An appeal is a formal way of asking HealthChoice to review and change its decision about covering your prescription drugs. Anytime HealthChoice makes a decision about covering or paying for your prescription drugs and you are unhappy with the decision, you can file an appeal. There are five levels of appeal beginning with a Level 1 Appeal. See Asking for a Level 1 Appeal section.
3If you Need Help During any
Part of the Grievance or Appeal Processes
If you need help during any part of the process, please contact HealthChoice Member Services at 1-405-717-8699 or toll-free 1-800-865-5142. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436. If a Member Services Representative cannot answer your question or resolve your problem, they can let you know who to contact.
At each step of the grievance or appeal processes, a letter is sent to you that provides information about what to do if you want to continue to the next level of appeal.
There are also other people who can help you during the grievance or appeal process.
• Your doctor or prescriber must act on your behalf by making the request for a prior authorization/exception. Your provider must give medical reasons to support any request for a prior authorization/exception or appeal.
• Your appointed representative, such as a relative or friend, can act for you. You must complete a HIPAA Authorization to Disclose Health Information form. See HIPAA Authorization to Disclose Health Information section below.
• Your lawyer can act on your behalf, but you are not required to hire a lawyer.
HIPAA Authorization to Disclose Health Information
If you want to appoint someone to represent you and act on your behalf, you must complete a HIPAA Authorization to Disclose Health Information form. This form is available on the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com. You can also request a form by contacting HealthChoice Member Services at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
If a Member Services Representative cannot answer your question or resolve your problem, they can let you know who to contact.
4Filing a Grievance
You must notify HealthChoice within 60 days of your problem if you want to file a grievance.
If you have a grievance, calling HealthChoice Member Services is the first step. When possible, a Member Services Representative will respond to your problem over the phone, or if there is anything else you need to do, they will let you know. You can also ask HealthChoice to respond to your concern in writing. Contact HealthChoice Member Services by calling 1-405-717-8699 or toll-free 1-800-865-5142. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
If you would prefer to put your grievance in writing, please mail it to:
HealthChoice
Attention: Medicare Grievances
3545 NW 58th Street, Suite 110
Oklahoma City, Oklahoma 73112
When you send a grievance to HealthChoice in writing, the Plan responds to you in writing.
If your grievance cannot be resolved over the phone or if you send your grievance in writing, HealthChoice reviews your grievance through a process known as the Employer PDP Medicare Supplement Grievance Procedure. HealthChoice must give you its decision as quickly as possible based on your health, but no later than 30 days of receiving your grievance. You or HealthChoice can extend this deadline for up to 14 additional days if the need for more information is justified and the delay is in your best interest.
Filing a grievance is the same as voicing a problem or concern. A grievance does not involve issues about coverage or payment for your prescription drugs. If you have a coverage or payment issue, please skip to Asking for a Coverage Decision section.
5Reasons to File a Grievance
If you have a problem with any of the issues listed in numbers 1 through 4 below, you have the option to file your grievance with HealthChoice, the Quality Improvement Organization (QIO), or both organizations. See Filing a Grievance with the Quality Improvement Organization section.
If you have a problem with any of the issues listed in numbers 5 through 16, you can file a grievance only with HealthChoice.
1. You are unhappy with the quality of care you received.
2. You think coverage for your hospital stay, home health care, skilled nursing facility care, or outpatient rehabilitation is ending too soon.
3. You were given the wrong drug or the wrong dosage of a drug.
4. You are allergic to or interacted in a negative way to a drug you were given.
5. You believe your privacy was not respected or someone shared your health information.
6. You believe you have been encouraged to leave (disenroll from) HealthChoice.
7. You are unhappy with the customer service you received.
8. You were kept waiting too long on the telephone or at the pharmacy.
9. You think someone has been rude or disrespectful to you.
10. You believe HealthChoice failed to provide notices as required by Medicare.
11. You believe HealthChoice failed to follow Medicare’s rules.
12. You think information HealthChoice provided to you is hard to understand.
13. You question the cleanliness or condition of a Network Pharmacy.
14. HealthChoice denied your request for a fast response to a coverage decision or appeal.
15. HealthChoice did not give you a decision within the required time frame.
16. HealthChoice did not forward your case to the Independent Review Entity when it failed to give you its decision within the required time frame.
6
If you have problems with issues 1 through 4, you can file your grievance with HealthChoice, the Quality Improvement Organization (QIO), or both organizations. If your problem involves issues 5 through 16 you must file your grievance with HealthChoice.Filing a Grievance with the Quality Improvement Organization
The Quality Improvement Organization (QIO) is a company Medicare pays to check on the quality of care for people enrolled in Medicare. In Oklahoma, the QIO is the Oklahoma Foundation for Medical Quality. Only grievances related to the quality of care you received can be reported to the Oklahoma Foundation for Medical Quality. Quality of care concerns are listed as numbers one through four* under Reasons to File a Grievance section.
If you have a grievance about the quality of care you received, you can file your grievance with HealthChoice, the Oklahoma Foundation for Medical Quality, or both organizations. Anytime a grievance is filed with the Quality Improvement Organization, HealthChoice must cooperate in resolving your problem.
To file a grievance with the Oklahoma Foundation for Medical Quality, call toll-free 1-800-522-3414 and ask for the Beneficiary Protection Unit. You need to provide your name, address, phone number, and a brief explanation of your grievance. A packet of information is then sent to you that includes the necessary forms and instructions for filing a formal grievance.
Your grievance must be reported within 60 days of the event that led to your issue.
If you prefer to put your grievance in writing, include your name, address, phone number, and a brief explanation of your issue. Mail your grievance to:
Oklahoma Foundation for Medical Quality
Attention: Beneficiary Protection Unit
14000 Quail Springs Parkway, Suite 400
Oklahoma City, Oklahoma 73134
* If you have a problem with any of the issues listed in numbers 5 through 16 under Reasons to File a Grievance section, you can file a grievance only with HealthChoice.
You can report your grievance to HealthChoice, the Quality Improvement Organization (QIO), or both. You must report your grievance to the QIO within 60 days of the event that led to your issue.
7Asking for a Coverage Decision
When HealthChoice makes a coverage decision, it is making a decision about whether or not to cover your drug, how much it will pay, and your share of the cost.
Usually, when you ask for a coverage decision, HealthChoice covers your drug and pays its share of the cost. However, in some cases, the Plan may decide that a drug is not covered, or is not covered for you, or you might be unhappy about the way HealthChoice decides to cover or not to cover your drug. If you disagree with the Plan’s decision, you can file a Level 1 Appeal.
Asking for a Prior Authorization/Exception
HealthChoice has rules and restrictions that apply to the way drugs are covered. If you disagree with these rules or restrictions, you can ask HealthChoice for a prior authorization/exception. When you ask for a prior authorization/exception, you are asking for a type of coverage decision.
Prior Authorization/Exception for a Covered Drug
Certain drugs listed in the HealthChoice Medicare Formulary require prior authorization/exception before they are covered by the Plan. Generally, these drugs are very high cost, have specific prescribing guidelines, are usually used for cosmetic purposes, or might be covered under Medicare Part B.
To request a prior authorization/exception for a covered drug, your doctor must contact Medco, the HealthChoice pharmacy benefits manager, and provide information to support your request. Your doctor can contact Medco toll-free at 1-800-753-2851.
If your request for a prior authorization/exception for a covered drug is approved, you can ask HealthChoice to provide your drug at the Preferred copay. To request a lower copay, you must complete a second prior authorization/exception process. See Prior Authorization/Exception for a Tier Exception to Receive a Lower Copay section.
Prior Authorization/Exception to the Plan’s Quantity Limitation Rules
Due to approved therapy guidelines, certain medications have set quantity limits. Quantity limitations may also apply if the medication form is other than a tablet or capsule.
If you want HealthChoice to reimburse you for a drug you already paid for, see Asking HealthChoice to Pay You Back for a Drug You Already Purchased section.
8To request a prior authorization/exception to the Plan’s quantity limitation rules, your doctor must contact Medco, the HealthChoice pharmacy benefits manager, and provide information to support your request. Your doctor can contact Medco toll-free at 1-800-753-2851.
Prior Authorization/Exception for a Non-Formulary or Non-Covered Drug*
If you want HealthChoice to pay for a non-formulary drug (a drug not listed on the HealthChoice Medicare Formulary) or for a non-covered drug*, you must ask for a prior authorization/exception. If your prior authorization/exception is approved, the Plan covers your drug, but you must pay the non-Preferred copay.
To request a prior authorization/exception to the HealthChoice Medicare Formulary, contact HealthChoice Member Services at 1-405-717-8699 or toll-free 1-800-865-5142. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
If your request for a prior authorization/exception for a non-formulary or non-covered drug is approved, you can ask HealthChoice to provide your drug at the Preferred copay. To request a lower copay, you must complete a second prior authorization/exception process. See Prior Authorization/Exception for a Tier Exception to Receive a Lower Copay section.
* Please note that HealthChoice does not cover all prescription drugs, and some drugs are never covered. In some instances, Medicare does not allow the Plan to cover certain drugs, and in other instances, HealthChoice has decided not to cover certain drugs.
Prior Authorization/Exception for a Tier Exception to Receive a Lower Copay
If you choose a non-Preferred medication when a Preferred medication is available, you must pay the non-Preferred copay unless you request a prior authorization/exception for a tier exception to receive a lower copay. Be aware that medical guidelines must be met, and information supplied by your doctor must justify your request.
To request a prior authorization/exception for a tier exception to receive a lower copay, your doctor must contact Medco, the HealthChoice pharmacy benefits manager, and provide information to support your request. Your doctor can contact Medco toll-free at 1-800-841-5409.
9Prior Authorization/Exception to the Step Therapy Process
Step therapy means you must try a specific, cost effective medication to treat your medical condition before HealthChoice covers another drug that is more costly or less cost effective. If you disagree with the step therapy process, you can ask HealthChoice for a prior authorization/exception to the process.
To ask for a prior authorization/exception to the step therapy process, your doctor must contact Medco, the HealthChoice pharmacy benefits manager, and provide information to support your request. Your doctor can contact Medco toll-free at 1-800-753-2851.
If the Plan says no to any request for a prior authorization/exception, you can file an appeal. See the Asking for a Level 1 Appeal section.
Asking for a Standard Decision
Generally, when you ask HealthChoice for a prior authorization/exception, the Plan makes a decision and gives you an answer within the standard time frame of 72 hours of receiving your request.
If HealthChoice says yes to part or all of your request for a prior authorization/exception, the authorization is loaded into the computer system within 72 hours of receiving your request.
If the Plan says no to your request for a prior authorization/exception, a letter that explains the reasons for the denial is sent to you. You have the right to appeal the Plan’s decision. See Asking for a Level 1 Appeal section.
Asking for a Fast Decision
If you or your doctors believe that waiting the standard 72 hours could harm your health or hurt your ability to function, you or your doctor can ask HealthChoice for a fast decision*. If you ask for a fast decision, the Plan must give you an answer within 24 hours or sooner if required due to your health. If HealthChoice does not meet this deadline, it must send your request on to Level 2 of the appeals process where it is reviewed by the Independent Review Organization.
When you ask for a prior authorization/exception, you must decide if you need a standard decision or a fast decision.
When you ask for a standard decision, you receive an answer within 72 hours. When you ask for a fast decision, you receive an answer within 24 hours.
10If your doctor or other prescriber tells HealthChoice that your health requires the Plan to make a fast decision, the Plan automatically gives you a fast decision.
If you ask for a fast decision on your own, without the support of your doctor or other prescriber, the Plan decides whether your health requires a fast decision.
If HealthChoice says yes to part or all of your request for a fast decision, the prior authorization/exception is loaded into the computer system within 24 hours of receiving your request.
If the Plan says no to your request for a fast decision, a letter that explains the reasons for giving you a standard decision rather than a fast decision is sent to you. The letter explains how you can ask for a fast grievance and receive an answer within 24 hours. See Filing a Grievance section.
* You cannot ask for a fast decision for a drug you already purchased.
11Asking HealthChoice to Pay You
Back for a Drug You Already Purchased
An event may occur that requires you to pay for a prescription drug yourself and then ask HealthChoice to pay you back. When you ask HealthChoice to pay you back for a drug you already purchased, it is a type of coverage decision. Examples of when you might need to pay the full cost for a drug include when:
• You use an out-of-network pharmacy.
• You don’t have your pharmacy ID card available when filling your prescription.
• HealthChoice is your secondary insurance plan.
• You pay the full cost for a drug for other reasons.
When you ask for reimbursement, the standard decision time frame always applies. You cannot request a fast decision when you ask for reimbursement.
If Your Request is Approved
If the drug you paid for is a covered drug and meets plan guidelines, HealthChoice sends you payment for its share of the cost.
If Your Request is Denied
If the Plan says no to your request, a letter that explains the reasons for the denial is sent to you. You can choose to accept this decision or file a Level 1 Appeal. The letter that explains the reasons for the denial provides information about how you can request a Level 1 Appeal. See Asking for a Level 1 Appeal section.
When you ask HealthChoice to pay you back for a drug you already purchased, the standard decision time frame always applies. You cannot ask for a fast decision for a drug you already received.
12Asking for a Level 1 Appeal
If HealthChoice denies your request for a prior authorization/exception, you can ask the Plan to review and reconsider its coverage decision. This is called a Level 1 Appeal.
When HealthChoice reviews your appeal, another careful look is taken at all the information you and/or your doctor provided in your first request. The Plan also checks to see if it was fair in following the rules when it denied your first request. During the appeals process, you may need to provide HealthChoice with more information.
You must ask for a Level 1 Appeal within 60 calendar days of the date on the letter that notified you of the denial of your first request. If you miss this deadline but have a good reason for missing it, HealthChoice can extend this deadline.
To ask for a Level 1 Appeal, you, your doctor, or your appointed representative must contact HealthChoice Member Services at 1-405-717-8699 or toll-free 1-800-865-5142. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436. Please ask for the Pharmacy Unit.
You can also ask for an appeal by sending written notice to:
HealthChoice
Attention: Pharmacy Unit
3545 NW 58th Street, Suite 110
Oklahoma City, OK 73112
or you can fax your request for an appeal to 1-405-717-8925.
You have the right to gather and include additional information in your request. You also have the right to ask HealthChoice for a copy of its information regarding your appeal; however, there may be a fee for copying and mailing as allowed by law.
Asking for a Standard Appeal
Generally, when you ask for a Level 1 Appeal, the Plan makes a decision and gives you an answer within the standard time frame of seven calendar days of receiving your appeal. If HealthChoice does not give you an answer within seven calendar days, the Plan must send your appeal on to Level 2 of the appeals process.
If your request for a prior authorization/exception is denied, you can ask HealthChoice to reconsider its decision by requesting a Level 1 Appeal.
13If HealthChoice says yes to part or all of your appeal, the Plan must provide coverage as quickly as your health requires but no later than seven calendar days of receiving your appeal.
Asking for a Fast Appeal
If your doctor or other prescriber believes that waiting the standard seven days could harm your health or hurt your ability to function, you can ask HealthChoice for a fast appeal*.
When you ask for a fast appeal, the Plan must give you an answer within 72 hours or sooner if required due to your health. If HealthChoice does not meet this deadline, the Plan must send your request on to Level 2 of the appeals process where it is reviewed by the Independent Review Organization.
If HealthChoice says yes to part or all of your appeal, the Plan must provide coverage as quickly as your health requires but no later than 72 hours of receiving your request.
If Your Level 1 Appeal is Denied
If the Plan says no to your Level 1 Appeal, a letter that explains the reasons for the denial is sent to you. You can choose to accept this decision or file a Level 2 Appeal. The letter that explains the reasons for the denial also provides information about how you can request a Level 2 Appeal.
* You cannot ask for a fast appeal for a drug you already purchased.
14Asking for a Level 2 Appeal
If HealthChoice denies any part of your Level 1 Appeal or refuses to pay you back for a drug you already purchased, you can ask for a Level 2 Appeal performed by the Independent Review Organization.
At this second level of appeal, a review is performed by an outside Independent Review Organization that is hired by Medicare. This organization is not a government agency and has no connection to HealthChoice. Medicare oversees the work the Independent Review Organization performs.
When HealthChoice receives your request for a Level 2 Appeal, it sends all the information about your appeal to the review organization. This information is called your case file. You have the right to ask HealthChoice for a copy of your case file; however, there may be a fee for copying and mailing as allowed by law.
The people at the review organization perform a careful review of all the information in your case file. They then reconsider the decision HealthChoice made. The Independent Review Organization gives you its decision in writing and includes the reasons for its decision.
You must ask for a Level 2 Appeal in writing within 60 calendar days of the letter that notified you of the denial of your Level 1 Appeal. The letter you receive that explains the reasons for the denial provides instructions for filing a Level 2 Appeal and includes the contact information for the Independent Review Organization.
Asking for a Standard Appeal
Generally, when you ask for a Level 2 Appeal, the review organization makes a decision and gives you an answer within the standard time frame of seven calendar days of receiving your appeal.
If the review organization says yes to part or all of your appeal, the Plan must provide the coverage the Independent Review Organization approved within 72 hours of receiving the organization’s decision.
If your Level 1 Appeal is denied or the Plan refuses to pay you back for a drug you already paid for, you can ask for a Level 2 Appeal.
15Asking for a Fast Appeal
If your health requires it, you can ask the Independent Review Organization for a fast appeal*. When you ask for a fast appeal, the review organization must give you an answer within 72 hours of receiving your appeal.
If the review organization says yes to part or all of your appeal, the Plan must provide the coverage the Independent Review Organization approved within 24 hours of receiving the organization’s decision.
If Your Level 2 Appeal is Denied
If the review organization says no to your Level 2 Appeal, it means they agree with the Plan’s decision to deny your request. This is also called upholding the decision or turning down your appeal.
If you want to file a Level 3 Appeal, your case must involve a coverage value of $130 or more. The letter you receive that explains the reasons for the denial tells you if your case meets the minimum requirements and provides information about how you can request a Level 3 Appeal.
If the dollar value of the coverage you are requesting does not meet the minimum value, you cannot make another appeal, and the decision made at Level 2 is final.
* You cannot ask for a fast decision for a drug you already purchased.
16Level 3, 4, and 5 Appeals
There are three additional levels of appeal following a Level 2 Appeal. This means there are a total of five levels of appeal. For each of the three remaining levels of appeal, the process works in much the same way as in Level 1 and Level 2 Appeals.
Asking for a Level 3 Appeal
If the Independent Review Organization does not rule completely in your favor and the dollar value of the coverage in question is enough, you can ask for a Level 3 Appeal. The letter you receive from the review organization explains the reasons for the denial of your Level 2 Appeal and also provides information about where and how to request a Level 3 Appeal.
Level 3 Appeals are conducted by an administrative law judge. The administrative law judge works for the federal government.
You must ask for review by an administrative law judge in writing within 60 calendar days of the letter that notified you of the denial of your Level 2 Appeal. You can request the administrative law judge extend this deadline if you have a good reason. During the administrative law judge’s review, you can present evidence, review the record, and be represented by counsel.
If the administrative law judge says yes to your appeal, the appeals process is over, and your request is approved.
If the administrative law judge says no to your appeal, a letter that explains the reasons for the denial is sent to you. You can choose to accept this decision or file a Level 4 Appeal. The letter that explains the reasons for the denial also tells you if the rules allow you to go on to a Level 4 Appeal. If the rules allow you to go on to the next level of appeal, the denial letter provides information about who to contact and what you need to do next.
Asking for a Level 4 Appeal
When you ask for a Level 4 Appeal, you ask for review and reconsideration by the Medicare Appeals Council. The Medicare Appeals Council does not review every case, so your case may or may not be reviewed. There is no minimum dollar value required for this review.
For each of the three remaining levels of appeal, the process works in much the same way as in Level 1 and Level 2 Appeals.
17You must ask for review by the Medicare Appeals Council in writing within 60 calendar days of the letter that notified you of the denial of your Level 3 Appeal.
If the council reviews your case and says yes to your request, the appeals process is over.
If the Medicare Appeals Council says no to your appeal, a letter that explains the reasons for the denial is sent to you. You can accept this decision or file a Level 5 Appeal in a federal district court.
The letter that explains the reasons for the denial also tells you if the rules allow you to go on to a Level 5 Appeal. If the rules allow you to go on to a Level 5 Appeal, your denial letter provides information about who to contact and what you need to do next.
If the coverage value is less than $1,300, the Medicare Appeals Council’s decision is final and you cannot take your appeal any further.
Asking for a Level 5 Appeal
If the coverage amount involved is $1,300 or more, you can ask for a Level 5 Appeal with a federal district court judge. You must ask for a Level 5 Appeal within 60 calendar days of the letter that notified you of the denial of your Level 4 Appeal. The letter you get from the Medicare Appeals Council provides information about how to request a Level 5 Appeal.
The judge’s decision in a Level 5 Appeal is final and you cannot take your appeal any further.
The flow chart on the next page shows, step-by-step, the Medicare Part D Appeals Process.
18Flow Chart for Medicare Part D Appeal Processes
Level 1 Appeal
You ask HealthChoice
to Reconsider its Decision
60 Days to File
Standard time frame – 7 Days
Fast time frame – 72 Hours
Coverage Decision
You ask HealthChoice for a
Prior Authorization/Exception
to its Pharmacy Rules
Standard time frame – 72 Hours
Fast time frame – 24 Hours
Level 3 Appeal
You ask for a Review by a
Federal Administrative Law Judge
60 Days to File
The coverage amount
must be greater than $130
Level 2 Appeal
You ask for a Review by the
Independent Review Organization
60 Days to File
Standard time frame – 7 Days
Fast time frame – 72 Hours
Level 4 Appeal
You ask for a Review by the
Medicare Appeals Council
60 Days to File
If the council doesn’t rule in your favor, you can file a Level 5 Appeal
Level 5 Appeal
You ask for a Review by a
Federal District Judge
60 Days to File
The coverage amount
must be greater than $1,300
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