MedicareComplete Medicare Part D Prescription Drug Appeals and Grievances

What is an Appeal?

An Appeal is a type of complaint you make when you want a redetermination and a change to a decision (Coverage Determination) we have made about what drugs are covered under your Medicare Advantage plan or what we will pay for a drug. You may also make a complaint if you disagree with a decision to stop coverage that you are receiving.

You, or your appointed representative, prescribing physician’s or other prescriber as appropriate may request a redetermination (Appeal) of an unfavorable Coverage Determination related to a Part D prescription drug. You may also Appeal the following situations:

• When a Coverage Determination is not provided in a timely manner.
• When a delay in a Coverage Determination would adversely affect your health.
• When a decision has been made that you do not meet the criteria for a Formulary exception.
• When a decision has been made that you do not meet the criteria for a copayment or coinsurance exception.

Medicare Advantage Medicare Part D Appeal Timeframes:

• Standard Appeals must be completed within seven (7) calendar days or sooner if your health requires.
• Expedited Appeals must be completed within seventy-two (72) hours.
• Extensions to timeframes are not permitted.

The first level of Appeal is considered a redetermination by the Centers for Medicare & Medicaid Services (CMS). The redetermination process is required to be completed within seven (7) calendar days of our receipt of the request, or sooner if your health requires. You must submit a written request for a redetermination to the Part D Prescription Appeals & Grievance Department, Physicians Health Choice, Attn: Appeals Dept., 5800 Northwest Parkway, Suite 125, San Antonio, TX 78249, or you may fax your written request to Attn: Part D Prescription Appeals & Grievances Department, 1-877-757-8889. You must submit your written request within sixty (60) calendar days of the date of the notice of the initial coverage determination.

You may also request an appeal by downloading and mailing in the Redetermination Request Form or by secure email.

You are not required to submit additional information to support your request for reconsideration (Appeal). We are responsible for gathering all necessary medical information. However, it may be helpful to include additional information to clarify or support your request. For example, you may want to include information in your Appeal request, such as medical records or physician opinions in support of your request.

Note: The sixty (60) calendar day limit may be extended for good cause. Include in your written request the reason you could not file within the sixty (60) calendar day timeframe.

We will conduct a redetermination and notify you in writing of the decision within seven (7) calendar days from the receipt of your request. Our reconsideration decision will be made by a person or persons not involved in the initial decision.

If we reverse the original adverse decision, we must authorize or provide coverage as expeditiously as your health requires, but no later than seven (7) calendar days from the date your request for an Appeal was received; or pay your claim within thirty (30) calendar days from the date your request for an Appeal was received.

If the redetermination is not completed within the required timeframe, we must submit the request to an Independent Review Entity (IRE) for review.

If you remain dissatisfied after the redetermination, you may request a further review known as a reconsideration. The reconsideration will be performed by the IRE. You, or your appointed representative prescribing physician or other prescriber, as appropriate, may request a reconsideration by the IRE within sixty (60) calendar days of receiving an adverse determination on a redetermination review.

The IRE will notify us that you have filed a reconsideration request. CMS requires the IRE to issue its reconsideration decision within seven (7) calendar days for a standard reconsideration, and within seventy-two (72) hours for expedited requests.

If the IRE maintains the denial, its notice will inform you of your right to a hearing before an administrative law judge (ALJ). You may request a hearing before an ALJ by submitting a written request to the entity specified in the IRE’s reconsideration notice. The request must be made within sixty (60) calendar days of the date of the IRE’s notice that the reconsideration decision was not in your favor. A hearing can be held only if the amount in controversy meets the dollar requirement established annually by the Secretary. The Administrative Law Judge will not review your appeal if the dollar value of the contested Part D benefit does not meet the minimum requirement provided in the independent review organization's decision. If the dollar value is less than the minimum requirement, you may not appeal any further.

If we have refused to provide Part D prescription drug benefits, the dollar value for requesting an Administrative Law Judge hearing is based on the projected value of those benefits. The projected value includes any costs you could incur based on the number of refills prescribed for the requested drug during the plan year. Projected value includes your copayments, all costs incurred after your costs exceed the initial coverage limit, and costs paid by other entities.

You may also combine multiple Part D claims to meet the dollar value if:

• The claims involve the delivery of Part D prescription drugs to you;
• All of the claims have received a determination by the independent review organization as described above;
• Each of the combined requests for review are filed in writing within sixty (60) calendar days after the date that each decision was made; and
• Your hearing request identifies all of the claims to be heard by the Administrative Law Judge.

How soon does the Judge make a decision?
The Administrative Law Judge will hear your case, weigh all of the evidence up to this point, and make a decision as soon as possible.

If the Judge decides in your favor:
The Administrative Law Judge will tell you in writing about his or her decision and the reasons for it. What happens next depends on the type of appeal:

• For a decision about payment for a Part D drug you already received. We must send payment to you no later that thirty (30) calendar days from the date we receive the determination.
• For a standard decision about a Part D drug you have not received. We must authorize or provide you with the Part D drug you have asked for within seventy-two (72) hours from the date we receive the determination.
• For a fast decision about a Part D drug you have not received. We must authorize or provide you with the Part D drug you have asked for within twenty-four (24) hours from the date we receive the determination.

If the Judge rules against you:
You have the right to appeal this decision by asking for a review by the Medicare Appeals Council. The letter you get from the Administrative Law Judge will tell you how to request this review.

If you are dissatisfied with an ALJ hearing decision, you may request a Medicare Appeals Council (MAC) review, which may either review the decision or decline to review. The notice you receive from the Administrative Law Judge will inform you how to request this review.

The Medicare Appeals Council (MAC) will first decide whether or not to review your case. There is no minimum dollar value for the MAC to hear your case. If you received a denial letter from the ALJ, you or your appointed representative can request a review by filing a written request from the Council.

The MAC does not review every case. If they decide not to review your case, then you may request a review by a Federal Court Judge. The MAC will issue a written notice advising you of any action taken with respect to your request for review. The notice will inform you how to request a review by a Federal Court Judge. If the MAC reviews your case, they will make a decision as soon as possible.

If the Council decides in your favor, it will notify you in writing of its decision. We will provide payment or authorization in the following timeframes:

• For a decision about payment for a Part D drug you have already received, we must send payment to you no later than thirty (30) calendar days from the date we receive the determination.
• For a standard decision about a Part D drug you have not received, we must authorize or provide you with the Part D drug you have requested within seventy-two (72) hours from the date we receive the determination.
• For an expedited decision about a Part D drug you have not received, we must authorize or provide you with the Part D drug you have requested within twenty-four (24) hours from the date we receive the determination.

If the Council maintains the denial, it will notify you in writing of its decision. You have the right to continue your appeal by asking a Federal Court Judge to review the case.

You may also request a Judicial review of the ALJ's decision if the MAC denied your request for review, and the amount involved meets the threshold requirement established annually by the Secretary. If the amount involved meets the minimum requirement provided in the Medicare Appeals Council's decision, you have the right to continue your appeal by asking a Federal Court Judge to review the case. If the value is less than the minimum requirement, the Council’s decision is final and you may not take the appeal any further. The MAC will send you a written notice advising you of any action taken with respect to your request for review. The notice will tell you how to request a review by a Federal Court Judge.

How soon will the Judge make a decision?
The Federal judiciary is in control of the timing of any decision.

If the Judge decides in your favor:
Once we get notice of a judicial decision in your favor, what happens next depends on the type of appeal:

• For a decision about payment for a Part D drug you already received. We must send payment to you within thirty (30) calendar days from the date we get notice reversing our coverage determination.
• For a standard decision about a Part D drug you have not received. We must authorize or provide you with the Part D drug you have asked for within seventy-two (72) hours from the date we get notice reversing our coverage determination.
• For a fast decision about a Part D drug you have not received. We must authorize or provide you with the Part D drug you have asked for within twenty-four (24) hours from the date we get notice reversing our coverage determination.

If the Judge decides against you:
The Judge’s decision is final and you may not take the appeal any further.

The following are not considered Coverage Determinations and do not constitute the right to Appeal:

• Transactions at the pharmacy counter are not Coverage Determinations.
• Information on a benefit plan design as it pertains to all members is not a Coverage Determination.
• The decision to place a drug on a Prior Authorization list is not a Coverage Determination and is not subject to Appeal.

Expedited/ Seventy-two (72) Hour Appeal Procedures
You have the right to request and receive an expedited seventy-two (72) hour redetermination (Appeal) in situations in which waiting for a redetermination (Appeal) decision to be made within the standard timeframe could seriously jeopardize your life, health, or your ability to regain maximum function. If we decide, based on medical criteria, that your situation is Time-Sensitive or if your prescribing physician or other prescriber calls or writes in support of your request for an expedited redetermination (Appeal) review, we will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request.

How To Request an Expedited Appeal
To request an expedited seventy-two (72) hour review, you or your authorized representative, prescribing physician or other prescriber, as appropriate, may call, write, fax or visit UnitedHealthcare. Be sure to ask for an expedited seventy-two (72) hour review when you make your request.

Call: 1-866-550-4736
October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday
For the hearing impaired: 711
October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday

Write: Part D Prescription Appeals & Grievance Department
Physicians Health Choice
Attn: Appeals Dept.
5800 Northwest Parkway, Suite 125
San Antonio, TX 78249
Fax: 1-877-757-8889

Expedited Appeals
Attn: Part D Prescription Appeals & Grievance Department – Expedited Appeal
Fax: 1-877-757-8889

Walk In:
5757 Plaza Drive
Cypress, CA 90630
8 a.m. to 5 p.m. PST
Monday through Friday

Note: The Appeals and Grievance Department will record the date and time of all telephone or fax requests for expedited seventy-two (72) hour reviews received on Saturday or Sunday or before or after business hours, Monday through Friday. The seventy-two (72) hour period for the expedited review will begin at the time received.

Upon receiving your redetermination request, we will determine if your request meets the definition of Time-Sensitive. Requests for redeterminations that include a doctor’s support will automatically be treated as an expedited Appeal.

If your request does not meet the definition of Time-Sensitive, it will be handled within the standard review process of seven (7) calendar days. You will be informed by telephone that your request for the expedited seventy-two (72) hour review has been denied and we will send a written confirmation within three (3) calendar days of the telephone call that the request will be processed within the standard review timeframe. If you disagree with our decision to process your request within the standard timeframe, you may file a Grievance with us. The written confirmation letter will include instructions on how to file a Grievance. If you have requested a fast decision, you will be notified of our Appeal decision within seventy-two (72) hours. We will send a follow-up decision letter within three (3) calendar days of the telephone call.

What is a Grievance?

A Grievance is a type of complaint that you make about us or one of our Plan providers, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

Grievance Procedures

If you have a grievance, we encourage you to first call Customer Service. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this our Formal Grievance process. This process is required to be complete within thirty (30) calendar days of our receipt of your request.

You may file your grievance with Physicians Health Choice by calling Customer Service at 1-866-550-4736 (TTY: 711) , October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, or mail your written complaint to:

Physicians Health Choice
Attn: Grievance Dept.
P.O. Box 690670
San Antonio, TX 78269-0670

You must submit your written request within sixty (60) calendar days of the date of the incident.
Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than thirty (30) calendar days after receiving your complaint. We may extend the timeframe by up to fourteen (14) calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

Asking for a "Fast" Grievance DeterminationDo you have a request for a Part D prescription drug coverage determination or redetermination that needs to be decided more quickly than the standard timeframe? If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination, you may request an expedited or “fast” grievance. If you disagree with our decision to process your request within the standard timeframe, you may file an expedited Grievance with us. The written confirmation letter will include instructions on how to file an expedited or “fast” Grievance.

How to request a Fast Grievance Determination
You may submit a written request for a Fast Grievance to the Part D Prescription Appeals & Grievance Department at P.O. Box 690670, San Antonio, TX 78269-0670, or

You may fax your written request to 1-877-757-8889.

You may call us to file an expedited grievance at:
1-866-550-4736 (TTY: 711) , October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday.
Please be sure to include the words “Fast”, “Expedited” or “24 hour review” on your request.

Complaints Involving Quality of Care Issues

All complaints that involve quality of care issues are referred to the UnitedHealthcare HealthServices Department for review. Complaints that affect an enrollee's immediate condition will receive immediate review. We will investigate the complaint with the involved providers and appropriate departments. You may need to sign an authorization to release your medical records.

We will confirm receipt of your complaint within thirty (30) calendar days of receiving your complaint. The results of the Quality Management review are confidential.

For quality of care complaints, you may also complain to the Quality Improvement Organization (QIO)
Complaints concerning the quality of care received under Medicare may be acted upon by the Medicare prescription drug plan under the grievance process, by an independent organization called the QIO, or by both. For example, if an enrollee believes his/her pharmacist provided the incorrect dose of a prescription, the enrollee may file a complaint with the QIO in addition to, or in lieu of, a complaint filed under the Part D plan's grievance process. For any complaint filed with the QIO, the Part D plan must cooperate with the QIO in resolving the complaint. For the QIO contact information in your area, please refer to your Evidence of Coverage.

How to file a quality of care complaint with the QIO

Quality of care complaints filed with the QIO must be made in writing. An enrollee who files a quality of care grievance with a QIO is not required to file the grievance within a specific time period. See the Evidence of Coverage for more information about how to file a quality of care complaint with the QIO.

Grievance, coverage determinations (including exceptions) and appeals process details can be found in the Evidence of Coverage.
To review the Evidence of Coverage, visit My Plan and choose your coverage area and plan type.

What if Physicians Health Choice won’t cover a drug I need?

If your pharmacist tells you that we don’t cover a drug you think should be covered, or it will cost you more than you think you are required to pay, you have the right to request a decision called a “coverage determination.” You can also ask for a coverage determination if we require you to try another drug before we pay for the drug prescribed for you, or there is a limit on the quantity or dose of the drug prescribed for you and you disagree with the limit.

If we don’t cover your drug, you can also pay for the prescription and request that we pay you back (this is also a coverage determination). You, your doctor, or your appointed representative can call or write a letter to your plan to request that the plan cover the prescription you need.

Once we have received the request, we have 72 hours (for a standard request) or 24 hours (for an expedited request) to notify you of our decision. Your request will be expedited if we determine (or your doctor tells us) that your health will be seriously jeopardized by waiting for a standard decision.

Part D Exceptions

An exception is a type of Part D coverage determination. You may request a tiering or formulary exception.

Tiering Exception: If granted, allows you to obtain a non-preferred drug at the cost-sharing amount applicable to drugs on the preferred tier.

Formulary Exception: If granted, you will have access to medically necessary Part D drugs that are not included on the Physicians Health Choice formulary. A formulary exception also permits you to request an exception to a quantity or dose limit or a requirement that you try another drug before Physicians Health Choice will pay for the requested drug.

You or your physician can begin the exceptions process by downloading, printing and completing the Medicare Part D Coverage Determination Request Form (PDF) – (for use by members and providers)

If your request is urgent, please call Customer Service at 1-866-550-4736 (TTY: 711), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday.

For more information on Part D coverage determinations and exceptions, refer to your Evidence of Coverage.

The Centers for Medicare and Medicaid Services (CMS) website provides specific information of particular importance to beneficiaries receiving Part D drug benefits through a Part D plan. Included on the CMS website are links to additional forms applicable to Part D grievances, coverage determinations and exceptions, and appeals processes.

Click Here > to access these additional forms.

The documents on our website are presented in PDF format. Click Here to install Adobe Acrobat.