If we make a coverage decision that you do not agree with, you can “appeal” the decision. An appeal is also called a redetermination or a level 1 appeal. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision.
For standard appeals, a decision will be made within 7 days of receiving your appeal.
You can request an expedited (fast) appeal if you or your doctor believe that your health could be seriously harmed by waiting up to 7 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.
To file an appeal:
- You, your authorized representative, or your doctor should make your request in writing and mail it to:
Prior Authorization Department, c/o Appeal Coordinator, P.O. Box 25184, Santa Ana, CA 92799.
- For expedited appeals, you or your doctor should call Member Services.
- You, your authorized representative, or your doctor may fax your request to 1-877-239-4565.
- You or your authorized representative must request an appeal within 60 calendar days from the date of the written notice of the plan’s coverage decision.
Your request for an appeal should include your name, your identification number, your date of birth, the name of the drug you need, and a contact phone number for you. You can include any paperwork that you feel may help your appeal.
Request for Redetermination Form
If we say no to your Level 1 Appeal, a written notice will be sent to you. The notice will include instructions on how to make a Level 2 Appeal (reconsideration) with the Independent Review Entity (IRE). The notice will also include deadlines you must follow. The IRE will review your appeal and make a decision, notifying you of the decision in writing.
Request for Reconsideration Form
You can find more detailed information about appeals in the Evidence of Coverage.
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.