MHI – Education & Resource Center

A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs. To request information for Aggregate Number of Grievances, Appeals and Exceptions to Grievances please call Member Services at (855) 540-4744 (TTY 711), 5 Days a Week, 8am to 8pm.

Some types of problems that might lead to filing a grievance include:

  • Issues with the service you receive from Member Services.
  • If you feel that you are being encouraged to leave (disenroll from) the plan.
  • If you disagree with our decision not to give you a "fast" decision or a "fast" appeal.
  • We don't give you a decision within the required time frame.
  • We don't give you required notices.
  • You believe our notices and other written materials are hard to understand.
  • Waiting too long for prescriptions to be filled.
  • Rude behavior by network pharmacists or other staff.
  • We don't forward your case to the Independent Review Entity if we do not give you a decision on time.
  • If you have any of these problems and want to make a complaint, it is called "filing a grievance."

Who may file a grievance

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. Other persons may already be authorized by the court or in accordance with State law to act for you.

If you want someone to act for you who is not already authorized by the court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call MHI Member Services.

Filing a grievance with our plan

The process for making a complaint is different than the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. We will try to resolve your complaint over the phone.

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 us.

  • Submit a written request for a grievance to
                     Attn: Part D Grievances
                     P.O. Box 3410
                     Lisle, IL 60532
                     Phone: (855) 540-4744 (TTY 711)
  • You may fax your written request toll-free to (866) 235-1571.

    If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.

    If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.

  • You may submit a written request for a Fast Grievance to the Medicare Part D Appeals & Grievance Dept. at PO Box 3410 Lisle, IL 60532-8410
  • You may fax your written request toll-free to (866) 235-1571
  • You may contact Members Health Insurance Company to file an expedited Grievance.

Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.

Whether you call or write, you should contact Member Services right away. The complaint must be made within sixty (60) calendar days after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in thirty (30) calendar days.

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

More information on how to file a complaint (also known as a grievance) please visit the website. 

Notice of Formulary Changes will be posted 60 days prior to the removal or change in the preferred or tiered cost-sharing status of a Medicare Part D drug. The posting will include:

  • The name of the affected covered Medicare Part D drug.
  • Information on whether the covered Medicare Part D drug is being removed from the formulary, or changing its preferred or tiered cost-sharing status.
  • The reason the covered Medicare Part D drug is being removed from the formulary, or changing its preferred or tiered cost-sharing status.
  • Alternative drugs in the same therapeutic category, class or cost-sharing tier, and the expected cost sharing for that drug.
  • The means by which members may obtain an updated coverage determination or an exception to a coverage determination.

An initial coverage determination is also called a coverage decision. A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs covered under the Part D benefit included in your plan. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you (or your doctor) don't agree with our coverage decision, you (or your doctor) may file an appeal.

In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to us to ask for a formal decision about the coverage.

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have restrictions that help ensure safe, effective and affordable drug use. If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you.

Restrictions on your drug apply to retail and mail service. You can find out if your drug has any restrictions by looking for the abbreviations next to the drug names in the plan's drug list. Please use the Farm Bureau Select Rx prescription drug list  or the Farm Bureau Essential Rx prescription drug list to identify the drugs covered by Farm Bureau Health Plans. Use this as a guide to help manage the overall cost of prescription drug benefits.

These may include:
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.
Quantity Limits (QL)
The plan will cover only a certain amount of this drug for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.
NOTE: If you do not get approval from the plan for a drug with a restriction or limit before using it, you may be responsible for paying the full cost of the drug.
You (and your doctor) can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.
Formulary Exceptions

  • You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred brand co-pay will apply. You cannot ask for an exception to the co-payment or co-insurance amount we require you to pay for the drug.
 Cost-Sharing Exceptions
  • If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it.
  • Drugs in some of our cost-sharing tiers are not eligible for this type of exception. For example, if we grant your request to cover a drug that is not on the plan’s Drug List, we cannot lower the cost-sharing amount for that drug. In addition:
    • Tier exceptions are not available for drugs in the Specialty Tier.
    • Tier exceptions are not available for drugs in the Preferred Generic Tier.
    • Tier exceptions are not available for branded drugs in the higher tiers if you ask for an exception for reduction to the generic-only tier level.
    • Tier exceptions may be granted only if there are alternatives in the lower tiers used to treat the same condition as your drug.

 Generally, the plan will only approve your request for an exception if your doctor provides information that the alternative drugs included in the plan's formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

Option 1:
Call the MHI Member Services number (1-855-540-4744/TTY 711) to request a coverage determination (coverage decision). When requesting a formulary or cost-sharing exception, or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the Drug List or its cost-sharing or coverage is limited in the upcoming year. If you are affected by a change in drug coverage you can:

  • Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. If we approve your request for a Formulary Exception, our approval is usually valid until the end of the plan year as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
  • Find a different drug that we cover. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. You should discuss that list with your doctor, who can tell you which drugs may work for you.

In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.

To initiate a coverage determination request, please contact 1-855-540-4744 (TTY 711).

Have the following information ready when you call:

  • Member name
  • Member date of birth
  • Medicare Part D Member ID number
  • Name of the medication
  • Physician's name
  • Physician's phone number
  • Physician fax number (if available)

Option 2:

You may also request a coverage decision/exception or prior authorization by logging on to and submitting a request. If you are a new user with, you will need to register before you can access any tool to assist you. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your doctor to get a supporting statement and/or additional clinical information needed to make a decision.

Forms you may need:

Option 3:

To initiate a request, providers may contact MHI at (855) 540-4744 (TTY 711) Monday through Friday, 8am - 8pm or fax toll-free to (800) 784-1580. The plan's decision on your exception request will be provided to you by telephone and/ or mail. In addition, the initiator of the request will be notified by telephone and/ or fax. 

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See the "MAKING AN APPEAL" section for instructions on how to appeal the decision.

An authorized representative is the person you designate to assist or handle affairs related to your healthcare services. The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during certain situations, such as filing an exception, appeal or a grievance.

Helpful forms you may need:
Download an Appointment of Representative Form

Both you and the person you have named as an authorized representative must sign the representative form. Please mail the completed form to: OptumRX, Attn: KS015-1000, Overland Park, KS 66211-2457 or fax to 1-866-889-2116. Please keep a copy of this form for your records. You also have the right to receive a copy of this authorization.
In some cases  if your prescribing doctor calls on your behalf, no representative form is required. 

You may also submit a written request. Be sure to include:

  • Your name, address, phone number, and Medicare number
  • A statement appointing someone as your representative
  • The name, address, and phone number of your representative
  • The professional status of your representative (like a doctor) or their relationship to you
  • A statement authorizing the release of your personal and identifiable health information to your representative
  • A statement explaining why you’re being represented and to what extent
  • Your signature and the date you signed the request
  • Your representative's signature and the date they signed the request

If you have questions about appointing a representative, please call Members Health Insurance at 855-540-4744, 8 am to 8 pm local time, 5 Days a week. Our automated phone system may answer your call during weekends and federal holidays from April 1 - September 30. TTY users should call 711. Or call Medicare at 1-800-MEDICARE (1-800-633-4227).

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.

When you make an appeal, we review the coverage decision we have 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.

How to appeal a decision about your prescription coverage

Appeal Level 1 - You may ask us to review an adverse coverage decision we've issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."

Appeal Level 2 – If we reviewed your appeal at “Appeal Level 1” and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).

When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.

To file an appeal:

  • Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. 
  • Send the letter or the Redetermination Request Form to
                  Members Health Insurance Company
                  Prior Authorization Department
                  c/o Appeals Coordinator
                  P.O. Box 25184
                  Santa Ana, CA 92799
                  Appeals Fax is 877-239-4565
                  Hours: 24/7             
  • You may also fax your letter of appeal to the Medicare Part D Appeals and Grievances Department toll-free at (877) 239-4565. You must mail your letter within 60 days of the date the adverse determination was issued, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline.
  • Note: if you are requesting an expedited (fast) appeal, contact Members Health Insurance.
  • The Medicare Part D Appeals and Grievance Department will look into your case and respond with a letter within 7 calendar days of receiving your request. You'll receive a letter with detailed information about the coverage denial.
  • The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.

    To inquire about the status of an appeal, contact 1-855-540-4744 (TTY 711).

Who may file your appeal of the coverage determination?

If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.

How soon must you file your appeal?

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How soon will we decide on your appeal?

  • For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:

    We will give you our decision within seven (7) calendar days of receiving the appeal request. If we do not give you our decision within seven (7) calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).

  • For a fast decision about a Medicare Part D drug that you have not yet received.

    We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

Next steps if the plan says "no"

If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).

If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.

To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact Members Health Insurance at 1-855-540-4744 (TTY 711).

The following information about your Medicare Part D Drug Benefit is available upon request:

  • Information on the procedures used to control utilization of services and expenditures.
  • Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
  • A summary of the compensation method used for physicians and other health care providers.
  • A description of our financial condition, including a summary of the most recently audited statement.

The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. Members Health Insurance offers the UM/QA program at no additional cost to its members and their providers.

Utilization management

The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Quality assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:

  • Clinically significant drug interactions
  • Therapeutic duplication
  • Inappropriate or incorrect drug therapy
  • Patient-specific drug contraindications
  • Over-utilization and under-utilization
  • Abuse or misuse

The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

For information about Payment Terms and Conditions please contact Member Services at (855) 540-4744 (TTY 711), 8am to 8pm, 5 Days a Week. 

Helpful Forms:

Credit Card Authorization (PDF)
Bank Withdrawal Pre-Authorization Form (PDF)
Part D Member Billing and Payment Fact Sheet (PDF)
Fraud, Waste and Abuse

Fraud, Waste and Abuse costs taxpayers billions of dollars each year and can put your health and welfare at risk. Healthcare fraud can increase the cost of prescription drugs as well as Part D plan expenses, such as premiums and amounts you pay out-of-pocket. Members Health Insurance Company (MHI) is committed to detecting, preventing and reporting healthcare fraud, waste and abuse.

What is Fraud, Waste and Abuse?

Fraud is knowingly and willingly misrepresenting or deceiving a healthcare program for the purpose of receiving money or services not owed.
Waste is the overutilization of services that, directly or indirectly, results in unnecessary costs to the healthcare program.
Abuse is an action that may, directly or indirectly, results in unnecessary costs to the healthcare program.

How to Prevent Fraud, Waste and Abuse

Medicare and health plan fraud can happen in a number of ways.  You play a vital role in protecting the Medicare program and your Members Health Insurance Company Part D plan program. 
Here’s how you can help:

Protect your Medicare number
  • Never allow another person to use your Medicare number and never use someone else’s Medicare number.
  • Only give your Medicare number to your doctors and other healthcare providers.

Protect your Part D plan identification number
  • Never allow another person to use your Part D plan identification number to obtain prescription drugs.
  • Only give your Part D plan identification number to your pharmacy.

Help prevent others from commiting fraud
  • Make sure a provider does not bill for services or prescriptions that you did not receive.
  • When a provider tells you equipment or services are free, they don’t need your Medicare number.
  • Review your Medicare Summary Notices and Monthly Prescription Drug Summary to make sure the services billed are correct. 
  • Make sure you only pay providers for the amount Medicare says you owe. 

Report other types of healthcare fraud
  • Providers billing for services not rendered.
  • Providers falsifying your medical records to obtain payment for services that may not be covered, such as cosmetic services or services that are not medically necessary.
  • Be suspicious when a provider tells you they know how to get Medicare or the health plan to pay for their services.

How to Report Fraud, Waste and Abuse
If you suspect or witness healthcare fraud, you should immediately report it to the Compliance Department of Members Health Insurance Company. 
Reporting to Members Health Insurance Company:
Email the MHI Compliance Department: 
Jason Beard, JD, CHPC, CHC
Associate General Counsel
Compliance Department Location:                   

Members Health Insurance Company
147 Bear Creek Pike
Columbia, TN  38401
Anonymous MHI Compliance Hotline:
Phone: 844-208-2110
Online Reporting:
All calls are confidential to the greatest extent possible. The caller’s identity will remain anonymous if desired.

To permit adequate information, all anonymous reports, either written or submitted via the Hotline, should contain the following information:
  • Date, time and place of incident;
  • Names of the individual(s) involved, if known;
  • Pertinent facts; and
  • Reason(s) why the person filing the report believes the incident raises compliance concerns.