If we make a coverage decision, whether before or after a service is received, and you are not satisfied, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. Under certain circumstances, which we discuss later, you can request an expedited or “fast appeal” of a coverage decision. Your appeal is handled by different reviewers than those who made the original decision.
When you appeal a decision for the first time, this is called a Level 1 appeal. In this appeal, we review the coverage decision we made to check to see if we were properly following the rules. When we have completed the review, we give you our decision.
For standard appeals, a decision will be made within 30 days of receiving your appeal. Standard Appeals are required to be submitted in writing.
You can request an expedited (fast) appeal if you or your doctor believe that your health could be seriously harmed by waiting up to 30 days for a decision. If your request to expedite the decision is granted, we must give you a decision no later than 72 hours after we receive your request or prescribing doctor's supporting statement. Expedited Appeals can be accepted over the phone by calling Member Services.
Here are resources if you decide to ask for any kind of coverage decision or appeal a decision:
- You can fax or mail us your written request for an appeal of a claim or medical service.
- You can call us at Member Services if medically necessary to request an expedited appeal.
- You can call us at Member Services to appeal a prescription drug determination. (A written appeal is not required when appealing Part D prescription drug coverage.)
- You can get free help from your State Health Insurance Assistance Program.
- Your doctor can make a request for you. If your doctor helps with an appeal past Level 2, they will need to be appointed as your representative. Please call Member Services and ask for the “Appointment of Representative” form. (The form is also available on Medicare’s website at cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf or on our website at www.fbhealthplans.com/medicare-advantage.
- For medical care or Part B prescription drugs, your doctor can request a coverage decision or a Level 1 appeal on your behalf. If your appeal is denied at Level 1, it will be automatically forwarded to Level 2.
- For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or a Level 1 appeal on your behalf. If your Level 1 appeal is denied your doctor or prescriber can request a Level 2 appeal.
- You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.
- If you want a friend, relative, or other person to be your representative, call Member Services and ask for the “Appointment of Representative” form. (The form is also available on Medicare’s website at cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf or on our website at www.fbhealthplans.com/medicare-advantage.
For more information from Medicare on making an appeal, click here to go to Medicare.gov.
For more information from Medicare on how to file a complaint, click here to go to Medicare.gov.
To request information for Aggregate Number of Grievances, Appeals and Exceptions to Grievances please call Member Services.