Drug Coverage Determinations
What is an appeal?
An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.
If we deny part or all or part of your request in our coverage determination, you may ask us to reconsider our decision. This is called an “appeal” or “request for redetermination.”
Please call us at (866) 314 2427 or TTY/TDD (888) 205 7671 if you need help with filing your appeal. You may ask us to reconsider our coverage determination, even if only part of our decision is not what you requested. When we receive your request to reconsider the coverage determination, we give the request to people at our organization who were not involved in making the coverage determination. This helps ensure that we will give your request a fresh look.
You can also call the Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-434-0222 if you would like to learn more about your options to appeal decisions. HICAP provides free, objective information and counseling on Medicare and other related topics. HICAP hasoffices in every county in California. To find the HICAP office in your area, please visit http://www.cahealthadvocates.org/HICAP/.
How you make your appeal depends on whether you are requesting reimbursement for a Part D drug you already received and paid for, or authorization of a Part D benefit (that is, a Part D drug that you have not yet received). If your appeal concerns a decision we made about authorizing a Part D benefit that you have not received yet, then you and/or your doctor will first need to decide whether you need a fast appeal. The procedures for deciding on a standard or a fast appeal are the same as those described for a standard or fast coverage determination.
Getting information to support your appeal
We must gather all the information we need to make a decision about your appeal. If we need your assistance in gathering this information, we will contact you. You have the right to obtain and include additional information as part of your appeal. For example, you may already have documents related to your request, or you may want to get your doctor’s records or opinion to help support your request. You may need to give the doctor a written request to get information.
You can give us your additional information in any of the following ways:
In writing, to Central Health Plan, Member Services Department, 1540 Bridgegate Drive, Diamond Bar, CA 91765.
By fax, at (626) 388-2361.
By telephone – if it is a fast appeal – at (866) 314 2427 or TTY/TDD (888) 205 7671
In person, at Member Services Department, 1540 Bridgegate Drive, Diamond Bar, CA 91765.
You also have the right to ask us for a copy of information regarding your appeal.
You can call us at (866) 314 2427 or TTY/TDD (888) 205 7671, or write us at Central
Health Medicare Plan, Member Services Department, 1540 Bridgegate Drive, Diamond Bar, CA 91765.
How soon must you file your appeal?
You need to file your appeal within 60 calendar days from the date included on the notice of our coverage determination. We can give you more time if you have a good reason for missing the deadline.
To file a standard appeal, you can send the appeal to us in writing at Central Health Medicare Plan, Member Services Department, 1540 Bridgegate Drive, Diamond Bar, CA 91765 or by fax to (626) 388 2361.
To file a standard appeal, you can also call us at (866) 314 2427 or TTY/TDD (888) 205 7671.
What if you want a fast appeal?
The rules about asking for a fast appeal are the same as the rules about asking for a fast coverage determination. You, your doctor, or your appointed representative can ask us to give a fast appeal (rather than a standard appeal) by calling us at (866) 314 2427 or TTY/TDD (888) 205 7671. Or, you can deliver a written request to Central Health Medicare Plan, Member Services Department, 1540 Bridgegate Drive, Diamond Bar, CA 91765, or fax it to (626) 388 2361. For after business hours request please call (866) 314 2427. Be sure to ask for a “fast,” "expedited," or “72-hour” review. Remember, that if your prescribing physician provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically treat you as eligible for a fast appeal.
How soon must we decide on your appeal?
How quickly we decide on your appeal depends on the type of appeal:
For a standard decision about a Part D drug, which includes a request for reimbursement for a Part D drug you already paid for and received.
After we receive your appeal, we have up to 7 calendar days to give you a decision, but will make it sooner if your health condition requires us to. If we do not give you our decision within 7 calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case.
For a fast decision about a Part D drug that you have not received.
After we receive your appeal, we have up to 72 hours to give you a decision, but will make it sooner if your health requires us to. If we do not give you our decision within 72 hours, an independent organization will review your case.
What happens next if we decide completely in your favor?
For a decision about reimbursement for a Part D drug you already paid for and received.
We must send payment to you no later than 30 calendar days after we receive your request to reconsider 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 as quickly as your health requires, but no later than 7 calendar days after we received your appeal.
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 72 hours of receiving your appeal – or sooner, if your health would be affected by waiting this long.
What happens next if we deny your appeal?
If we deny any part of your appeal, you or your appointed representative have the right to ask an independent organization, to review your case. This independent review organization contracts with the federal government and is not part of Central Health Medicare Plan. Refer to your Evidence Of Coverage booklet or contact Medicare as follows:
Call 1-800-MEDICARE (1-800-633-4227) to ask questions or get free information booklets from Medicare. You can call this national Medicare helpline 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048. Calls to these numbers are free.
Use a computer to look at www.medicare.gov, the official government website for Medicare information. This website gives you a lot of up-to-date information about Medicare and nursing homes and other current Medicare issues. It includes booklets you can print directly from your computer. It has tools to help you compare Medicare Advantage Plan and Prescription Drug Plans in your area. You can also search the “Helpful Contacts” section for the Medicare contacts in your state. If you do not have a computer, your local library or senior center may be able to help you visit this website using their computer.
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