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
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.