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Grievances, Appeals and Exceptions Information

"Appeals" and "grievances" are the two different types of complaints you can make. A general overview of our policies is provided.
  • For information on our Grievance and Appeals Process, please see the section of your Evidence of Coverage (EOC) document titled "What to Do If You Have a Problem or Complaint (Coverage Decisions, Appeals, Complaints)". This section of your EOC document explains how to ask for coverage decisions and make appeals if you are having trouble getting the prescription drugs or medical services you think are covered by our plan.  This includes, but is not limited to, asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon.
  • The EOC document also explains how to make complaints about quality of care, waiting times, customer service, and other concerns.
We Listen to Your Concerns

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 Medicare Advantage prescription drug (MAPD) plans (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.

To obtain an aggregate number of grievances, appeals and exceptions filed or for full information on benefits, please call Customer Service.

 

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 page:
  • 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.
Coverage Determination and Prior Authorization Request Form for Providers:
Coverage Determination and Prior Authorization Request Form for Members:
  • Medicare Prescription Drug Determination Request Form (for use by all members): (Empire BlueCross BlueShield) Need to request an exception to the formulary? This form contains the coverage determination (including exceptions) request form. You or your provider 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: medicarepartdparequests@express-scripts.com Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
  • Medicare Prescription Drug Determination Request Form (for use by all members): (Empire BlueCross) Need to request an exception to the formulary? This form contains the coverage determination (including exceptions) request form. You or your provider can 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: medicarepartdparequests@express-scripts.com Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
Redetermination Request Forms for Members and Providers:

An appeal to use about a Part D drug coverage decision is called a plan "redetermination". 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 877-657-6115, 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 download the Medicare Advantage General Precertification Request form and submit it to the address listed on the form in order to request an organization determination:
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:
Medicare Programs
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:
Medicare Programs
Appeals and Grievances Department
Mailstop: OH0205-A537
4361 Iriwn 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:
  • Conditions and Limitations (Empire BlueCross): 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 BlueShield) 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.
  • Out of Network Prescription Drug Coverage (Empire BlueCross): Review the procedures for filling prescriptions outside of the network
  • Out of Network Prescription Drug Coverage (Empire BlueCross BlueShield): 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 Formulary Transition Notice

 

How do I request an exception to the formulary?
To submit a request for a coverage determination, utilization exception, formulary exception, or tiering exception:

 

Important Information about premiums:

If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months for it take effect and you will ultimately be held responsible for those premiums.

You may be able to get extra help to pay for your prescripton drug premiums and costs.

For more information about receiving extra help to pay for your prescription drug coverage, select a plan and review the LIS (Low Income Subsidy) Premium Summary Chart.

To see if you qualify for getting extra help, you may also call:

  • 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7days a week), or
  • The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call, 1-800-325-0778, or
  • Your State Medicaid Office.
*In certain cases, CMS systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. In order to address these special situations, CMS has created the Best Available Evidence (BAE) policy. This policy requires Part D plans to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate.  For more information about this CMS policy, click here

If you have qualified for additional assistance for your Medicare Prescription Drug Plan costs, the amount of your premium and cost at the pharmacy will be less. Once you have enrolled in a (PDP) plan, Medicare will tell us how much assistance you are receiving, and we will send you information on the amount you will pay. If you are not receiving this additional assistance, you should contact 1-800-MEDICARE (TTY/TTD users call 877-486-2048), your state Medicaid Office, or local Social Security Administration Office to see if you might qualify.

Contract Renewal
Our prescription drug plan (PDPs) and Medicare Advantage prescription drug (MAPD) plans have a Medicare contract. Since contracts with Medicare are renewed annually, both the Prescription Drug Plans and the Medicare Advantage prescription drug (MAPD) plans cannot guarantee availability of coverage beyond the end of their current contract year.

If our Medicare contract is terminated or if we stop offering PDP or MAPD benefits, we will give you written notice of when that change will be effective. We will also provide you with information about alternative Prescription Drug Plans or Medicare Advantage prescription drug (MAPD) plans in your area, and the steps you need to take to continue your prescription drug coverage with Medicare. At that time, you would be eligible for a Special Enrollment Period, and could choose a new PDP sponsor or MAPD sponsor without being subject to a late enrollment penalty.

Contract Termination Procedures

All Medicare Prescription Drug Plans and Medicare Advantage prescription drug (MAPD) plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Prescription Drug Plan or Medicare Advantage prescription drug (MAPD) plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 60 days before your coverage will end. The letter will explain your options for Medicare prescription drug coverage in your area.
Materials may be available in alternative formats.