"Appeals" and "grievances" are the two different types of complaints you can make. A general overview of our policies is provided.
We do our best to give you all the information you need to make the most of your benefits, and we listen to any concerns. You have the right to make a complaint if you have concerns or problems related to your prescription drug coverage or the services you receive.
We have procedures to help ensure that appeals and grievances are answered in a timely manner. More information about these procedures is available in our member materials for our prescription drug plan (PDPs) (which you can view on the Documents tab once you select a plan). You should also know that we have developed procedures to monitor the quality of your service, which are listed on the Documents tab under Quality Assurance Procedures.
Contact Information for the Medicare Beneficiary Ombudsman
Contact Information for Process or Status Questions
If you are a member or provider and you are submitting a grievance, appeal, coverage determination, or redetermination request, an exception, or an organization determination request, please use the contact number for process or status questions that is listed for the plan and contact Customer Service
The following information for the plan is also listed on the Customer Service
- Phone number(s) for receiving oral requests for a grievance, an organization/coverage determination, and an appeal.
- Mailing address and fax number for written requests for a grievance, an organization/coverage determination, and an appeal.
Process for Making Complaints:
The formal name for making a complaint is filing a grievance.
- Usually, calling Customer Service is the first step. If there is anything else you need to do, Customer Service will let you know. You can call the Customer Service phone number listed on you member ID card to submit an oral grievance.
- If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to Grievances & Appeals at the mailing address or fax number listed for your plan. If you put your complaint in writng, we will respond to your complaint in writing. You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. If you want someone to act for you who is not already authorized by the court or under state law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call Customer Service. You can mail or fax the Appointment of Representative Form to Customer Service.
Process for Coverage Decisions and Appeals:
For some types of problems, you need to use the process for coverage decisions and making appeals, which deals with problems related to your benefits and coverage for medical services and prescription drugs, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered. If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:
- You can call us at Customer Service
- For Part D prescription drugs, your doctor or other prescriber can request a coverage determination or an appeal on your behalf.
- For medical care, a doctor can request a coverage decision or appeal on your behalf.
What form do members or providers use for Coverage Determination and Prior Authorization requests?
Members or providers can download the form and fax it to Express Scripts at 1-877-526-2307. Express Scripts, Inc. is a separate company that manages pharmacy services and benefits for Empire BlueCross and BlueShield and Empire BlueCross.
This form is used by members or providers to:
- provide a supporting statement for a formulary exceptions request
- submit a prior authorization request for a drug
- submit a request for a coverage determination for a drug
Or, a provider may submit an electronic prior authorization request on behalf of the member. Submitting electronic prior authorization requests for prescribed medications can mean faster processing and saves the provider from having to call or send faxed requests. A provider can submit a Medicare ePA (Electronic Prior Authorization) on behalf of a member in one of two ways:
Redetermination Request Forms for Members and Providers:
An appeal to use about a Part D drug coverage decision is called a plan "redetermination". The Redetermination Request Form provides basic information to enrollees and prescribers on how to ask for a redetermination from a Medicare drug plan.
The forms for submitting a redetermination request are listed below:
Requesting an Organization Determination for a Medicare Advantage coverage decision:
When a coverage decision involves your medicare care, it is called an "organization determination". An organization determination is any determination (i.e. an approval or denial) made by the Medicare health plan, or its delegated entity with respect to the following:
- Payment for temporarily out of the area renal dialysis services;
- Payment for emergency services, post-stabilization care, or urgently needed services;
- Payment for any other health services furnished by a provider (other than the Medicare health plan), that the member believes:
- Are covered under Medicare, or
- If not covered under Medicare, should have been furnished, arranged for, or reimbursed by the Medicare health plan.
- Refusual to authorize, provide, or pay for services, in whole or in part, including the type or level of services, which the member believes should be furnished or arranged by the organization;
- Reduction, or premature discontinuation, or a previously authorized ongoing course of treatment; or
- Failure of the Medicare health plan to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the member with timely notice of an adverse determination, such that a delay adversely affects the health of the member.
Medicare Advantage plans require precertification for in network providers. Providers should call 866-797-9884, from 8am -5pm EST, Monday – Friday, or the telephone number listed on the back of the member’s ID card for precertification requirements, verification of member eligibility, benefits and account information.
Providers can call us at Customer Service
to submit an oral request for an organization determination, or submit a written request for an organization determination and mail it to:
3350 Peachtree Rd NE
Atlanta, GA 30326
Request forms can also be faxed to: 800-464-5942.Standard written requests can also be mailed or faxed to
Appeals and Grievances Department
4361 Irwin Simpson Road
Mason, Ohio 45040
Fax number: 888-458-1406
Medicare Advantage Prescription Drug (MAPD) Plan - Prescription Drug Information - Conditions, Limitations, Out of Network Drug Coverage
By law, certain types of drugs or categories of drugs are not covered by Medicare Prescription Drug Plan sponsors. These drugs or categories of drugs are called "exclusions". Please note that excluded drugs cannot be requested as an exception
- Conditions and Limitations (Empire BlueCross) – for Empire MediBlue Access (PPO) plans
- Conditions and Limitations: (Empire BlueCross BlueShield) – for Empire MediBlue Access (PPO), Empire MediBlue Plus (HMO), Empire MediBlue Choice (HMO-POS), and Empire MediBlue Dual Advantage (HMO SNP) plans
Review the procedures for filling prescriptions outside of the network:
Process for Exceptions to the List of Covered Drugs (formulary):
Here are examples of coverage decisions you ask us to make about your Part D drugs:
You ask us to make an exception, including:
- Asking us to cover a Part D drug that is not on the plan's List of Covered Drugs (Formulary)
- Asking us to waive a restriction on the plan's coverage for a drug (such as limits on the amount of the drugs you can get)
- Asking to pay a lower cost-sharing amount for a nonpreferred drug
Review the Prescription Drug Transition Policy
To submit a request for a coverage determination, utilization exception, formulary exception, or tiering exception:
Medicare Part D enrollees can use this form to request coverage determinations (including tiering, utilization or formulary exception requests) from their Medicare Part D plan sponsor. You or your physician can send a request for a prescription coverage determination or an appeal for a Medicare plan via email by sending the request to the following address: email@example.com
Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
A provider can submit a Medicare ePA (Electronic Prior Authorization) on behalf of a member in one of two ways: