Wellcare Fidelis Dual Align (HMO D-SNP)

Coverage Decisions and Appeals

1. A Guide to the basics of coverage decisions and appeals

1.1. Asking for coverage decisions and making appeals: the big picture

Coverage decisions and appeals deal with problems related to your benefits and coverage, including payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered.

Asking for coverage decisions prior to receiving services

A coverage decision is a decision we make about your benefits and coverage for your medical services or drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

In limited circumstances a request for a coverage decision will be dismissed, which means we won't review the request. Examples of when a request will be dismissed include if the request is incomplete if someone makes the request on your behalf but isn't legally authorized to do so or if you ask for your request to be withdrawn. If we dismiss a request for a coverage decision, we will send a notice explaining why the request was dismissed and how to ask for a review of the dismissal.

We are making a coverage decision for you whenever we decide what is covered for you. In some cases, we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Making an appeal

If we make a coverage decision, whether before or after a service is received, and you are not satisfied, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. Under certain circumstances, which we discuss later, you can request an expedited or "fast appeal" of a coverage decision. Your appeal is handled by different reviewers than those who made the original decision.

When you appeal a decision for the first time, this is called a Level 1 appeal. In this appeal, we review the coverage decision we made to check to see if we were properly following the rules. When we have completed the review, we give you our decision.

In limited circumstances a request for a Level 1 appeal will be dismissed, which means we won't review the request. Examples of when a request will be dismissed include if the request is incomplete, if someone makes the request on your behalf but isn't legally authorized to do so or if you ask for your request to be withdrawn. If we dismiss a request for a Level 1 appeal, we will send a notice explaining why the request was dismissed and how to ask for a review of the dismissal.

If we do not dismiss your case but say no to all or part of your Level 1 appeal, you can go on to a Level 2 appeal. The Level 2 appeal is conducted by an Independent Review Entity that is not connected to us.

• Appeals for medical services and Part B drugs will be automatically sent to the independent review organization for a Level 2 appeal - you do not have to do anything. The independent review organization will mail you a notice to confirm they received your Level 2 appeal. For Part D drug appeals, if we say no to all or part of your appeal you will need to ask for a Level 2 appeal (Part D appeals are discussed further in Section 2).


• See Section 2.4 for more information about Level 2 appeals.

If you are not satisfied with the Level 2 appeal decision, you may be able to continue through additional levels of appeal (Section 6 explains the Level 3, 4, and 5 appeals processes).

1.2. How to get help when you are asking for a coverage decision or making an appeal

Here are resources if you decide to ask for any kind of coverage decision or appeal a decision:

• You can Contact Us.


• You can get free help from your State Health Insurance Assistance Program.


• Your doctor or other health care provider can make a request for you. If your doctor helps with an appeal past Level 2, they will need to be appointed as your representative. Please complete the Appointment of Representative Form - English (PDF) or Appointment of Representative Form - Spanish (PDF).
  
  
  • For medical care, your doctor or other health care provider can request a coverage decision or a Level 1 appeal on your behalf. If your appeal is denied at Level 1, it will be automatically forwarded to Level 2.
  
  
  • If your doctor or other health provider asks that a service or item that you are already getting be continued during your appeal, you may need to name your doctor or other prescriber as your representative to act on your behalf.
  
  
  • For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or a Level 1 appeal on your behalf. If your Level 1 appeal is denied your doctor or prescriber can request a Level 2 appeal.


• You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal.
  
  
  • If you want a friend, relative, or other person to be your representative, please complete the Appointment of Representative Form - English (PDF) or Appointment of Representative Form - Spanish (PDF). The form gives that person permission to act on your behalf. It must be signed by you and by the person you would like to act on your behalf. You must give us a copy of the signed form.
  
  
  • While we can accept an appeal request without the form, we cannot begin or complete our review until we receive it. If we do not receive the form, your appeal request will be dismissed. If this happens, we will send you a written notice explaining your right to ask the independent review organization to review our decision to dismiss your appeal.


• You also have the right to hire a lawyer. You may contact your own lawyer or get the name of a lawyer from your local bar association or other service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision.

1.3. Which section of this page gives the details for your situation?

There are four different situations that involve coverage decisions and appeals. Since each situation has different rules and deadlines, we give the details for each one in a separate section:

• Section 2, "Your medical care: How to ask for a coverage decision or make an appeal"


• Section 3, "Your Part D prescription drugs: How to ask for a coverage decision or make an appeal"


• Section 4, "How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon"


• Section 5, "How to ask us to keep covering certain medical services if you think your coverage is ending too soon" (This section only applies to these services: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services)

If you're not sure which section you should refer to, Contact Us. You can also get help or information from government organizations such as your SHIP.

2. Your medical care: How to ask for a coverage decision or make an appeal of a coverage decision

2.1. This section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for your care

This section is about your benefits for medical care and services. To keep things simple, we generally refer to "medical care coverage" or "medical care" which includes medical items and services as well as Medicare Part B prescription drugs. In some cases, different rules apply to a request for a Part B prescription drug. In those cases, we will explain how the rules for Part B prescription drugs are different from the rules for medical items and services.

This section tells what you can do if you are in any of the five following situations:

1. You are not getting certain medical care you want, and you believe that our plan covers this care. Ask for a coverage decision. Section 2.2.


2. Our plan will not approve the medical care your doctor or other health care provider wants to give you, and you believe that our plan covers this care. Ask for a coverage decision. Section 2.2.


3. You have received medical care that you believe our plan should cover, but we have said we will not pay for this care. Make an appeal. Section 2.3.


4. You have received and paid for medical care that you believe our plan should cover, and you want to ask our plan to reimburse you for this care. Send us the bill. Section 2.5.


5. You are being told that coverage for certain medical care you have been getting (that we previously approved) will be reduced or stopped, and you believe that reducing or stopping this care could harm your health. Make an appeal. Section 2.3.

Note: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services, you need to read a Sections 4 and 5. Special rules apply to these types of care.

2.2. Step-by-step: How to ask for a coverage decision

Step 1: Decide if you need a "standard coverage decision" or a "fast coverage decision."

A "standard coverage decision" is usually made within 14 days or 72 hours for Part B drugs. A "fast coverage decision" is generally made within 72 hours, for medical services, 24 hours for Part B drugs. In order to get a fast coverage decision, you must meet two requirements:

• You may only ask for coverage for medical care you have not yet received.


• You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.


• If your doctor tells us that your health requires a "fast coverage decision," we will automatically agree to give you a fast coverage decision.


• If you ask for a fast coverage decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision. If we do not approve a fast coverage decision, we will send you a letter that:
  
  
  • Explains that we will use the standard deadlines
  
  
  • Explains if your doctor asks for the fast coverage decision, we will automatically give you a fast coverage decision
  
  
  • Explains that you can file a "fast complaint" about our decision to give you a standard coverage decision instead of the fast coverage decision you requested.

Step 2: Ask our plan to make a coverage decision or fast coverage decision.

• Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this.

Step 3: We consider your request for medical care coverage and give you our answer.

For standard coverage decisions we use the standard deadlines.

This means we will give you an answer within 14 calendar days after we receive your request for a medical item or service. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request.

• However, if you ask for more time, or if we need more information that may benefit you, we can take up to 14 more days if your request is for a medical item or service. If we take extra days, we will tell you in writing. We can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.


• If you believe we should nottake extra days, you can file a "fast complaint." We will give you an answer to your complaint as soon as we make the decision. (The process for making a complaint is different from the process for coverage decisions and appeals. See Section 6 for information on complaints.)

For Fast Coverage decisions we use an expedited timeframe.

A fast coverage decision means we will answer within 72 hours if your request is for a medical item or service. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours.

• However, if you ask for more time, or if we need more that may benefit you, we can take up to 14 more days. lf we take extra days, we will tell you in writing. We can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.


• If you believe we should not take extra days, you can file a "fast complaint". (See Section 6 for information on complaints.) We will call you as soon as we make the decision.


• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Step 4: If we say no to your request for coverage for medical care, you can appeal.

• If we say no, you have the right to ask us to reconsider this decision by making an appeal. This means asking again to get the medical care coverage you want. If you make an appeal, it means you are going on to Level 1 of the appeals process.

2.3. Step-by-step: How to make a Level 1 appeal

Step 1: Decide if you need a "standard appeal" or a "fast appeal."

A "standard appeal" is usually made within 30 days. A "fast appeal" is generally made within 72 hours.

• If you are appealing a decision we made about coverage for care that you have not yet received, you and/or your doctor will need to decide if you need a "fast appeal." If your doctor tells us that your health requires a "fast appeal," we will give you a fast appeal.


• The requirements for getting a "fast appeal" are the same as those for getting a "fast coverage decision" in Section 2.2.

Step 2: Ask our plan for an appeal or a fast appeal

• If you are asking for a standard appeal, submit your standard appeal in writing. You may also ask for an appeal by calling us.


• If you are asking for a fast appeal, make your appeal in writing or Contact Us .


• You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer on the coverage decision. If you miss this deadline and have a good reason for missing it, explain the reason your appeal is late when you make your appeal. We may give you more time to make your appeal. Examples of good cause may include a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.


• You can ask for a free copy of the information regarding your medical decision. You and your doctor may add more information to support your appeal.

If we told you we were going to stop or reduce services or items that you were already getting, you may be able to keep those services or items during your appeal.

• If we decided to change or stop coverage for a service or item that you currently get, we will send you a notice before taking the proposed action.


• If you disagree with the action, you can file a Level 1 appeal. We will continue covering the service or item if you ask for a Level 1 appeal within 10 calendar days of the postmark date on our letter or by the intended effective date of the action, whichever is later.


• If you meet this deadline, you can keep getting the service or item with no changes while your Level 1 appeal is pending. You will also keep getting all other services or items (that are not the subject of your appeal) with no changes.

Step 3: We consider your appeal and we give you our answer.

• When we are reviewing your appeal, we take a careful look at all of the information. We check to see if we were following all the rules when we said no to your request.


• We will gather more information if needed, possibly contacting you or your doctor.

Deadlines for a "fast appeal"

• For fast appeals, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to.
  
  
  • However, if you ask for more time, or if we need more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we take extra days, we will tell you in writing. We can't take extra time if your request is for a Medicare Part B prescription drug.
  
  
  • If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. Section 2.4 explains the Level 2 appeal process.


• If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal.


• If our answer is no to part or all of what you requested, we will send you our decision in writing and automatically forward your appeal to the independent review organization for a Level 2 appeal. The independent review organization will notify you in writing when it receives your appeal.

Deadlines for a "standard" appeal

• For standard appeals, we must give you our answer within 30 calendar days after we receive your appeal. If your request is for a Medicare Part B prescription drug you have not yet received, we will give you our answer within7 calendar days after we receive your appeal. We will give you our decision sooner if your health condition requires us to.
  
  
  • However, if you ask for more time, or if we need more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we take extra days, we will tell you in writing. We can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.
  
  
  • If you believe we should not take extra days, you can file a "fast complaint." When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (For more information about the process for making complaints, including fast complaints, refer to your Evidence of Coverage.)
  
  
  • If we do not give you an answer by the deadline (or by the end of the extended time period), we will send your request to a Level 2 appeal where an independent review organization will review the appeal. Section 2.4 explains the Level 2 appeal process.


• If our answer is yes to part or all of what you requested, we must authorize or provide the coverage within 30 calendar days, or within 7 calendar days if your request is for a Medicare Part B prescription drug, after we receive your appeal.


• If our plan says no to part or all of your appeal, you have additional appeal rights.


• If we say no to part or all of what you asked for, we will send you a letter.
  
  
  • If your problem is about coverage of a Medicare service or item, the letter will tell you that we sent your case to the independent review organization for a Level 2 appeal.
  
  
  • If your problem is about coverage of a Medicaid service or item, the letter will tell you how to file a Level 2 appeal yourself.

2.4. Step-by-step: How a Level 2 appeal is done

The independent review organization is an independent organization hired by Medicare. It is not connected with us and is not a government agency. This organization decides whether the decision we made is correct or if it should be changed. Medicare oversees its work.

• If your problem is about a service or item that is usually covered by Medicare, we will automatically send your case to Level 2 of the appeals process as soon as the Level 1 appeal is complete.


• If your problem is about a service or item that is usually covered by Medicaid, you can file a Level 2 appeal yourself. The letter will tell you how to do this. Information is also below.


• If your problem is about a service or item that could be covered by both Medicare and Medicaid, you will automatically get a Level 2 appeal with the independent review organization. You can also ask for a review by the state's Independent Utilization Review Organization (IURO), and a Fair Hearing with the state.

If you qualified for continuation of benefits when you filed your Level 1 appeal, your benefits for the service, item, or drug under appeal may also continue during Level 2. Go to page 138 for information about continuing your benefits during Level 1 appeals.

• If your problem is about a service that is usually covered by Medicare only, your benefits for that service will not continue during the Level 2 appeals process with the independent review organization.


• If your problem is about a service that is usually covered by Medicaid, your benefits for that service will continue if you submit a Level 2 appeal within 10 calendar days after receiving the plan's decision letter or by the intended effective date of the action, whichever is later.

If your problem is about a service or item Medicare usually covers:

Step 1: The independent review organization reviews your appeal.

• We will send the information about your appeal to this organization. This information is called your "case file." You have the right to ask us for a free copy of your case file.


• You have a right to give the independent review organization additional information to support your appeal.


• Reviewers at the independent review organization will take a careful look at all of the information related to your appeal.

If you had a "fast" appeal at Level 1, you will also have a "fast" appeal at Level 2

• For the "fast appeal" the review organization must give you an answer to your Level 2 appeal within 72 hours of when it receives your appeal.


• If your request is for a medical item or service and the independent review organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The independent review organization can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.

If you had a "standard" appeal at Level 1, you will also have a "standard" appeal at Level 2

• For the "standard appeal" if your request is for a medical item or service, the review organization must give you an answer to your Level 2 appeal within 30 calendar days of when it receives your appeal.


• If your request is for a Medicare Part B prescription drug, the review organization must give you an answer to your Level 2 appeal within 7 calendar days of when it receives your appeal.


• However, if your request is for a medical item or service and the independent review organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The independent review organization can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.

Step 2: The independent review organization gives you their answer.

The independent review organization will tell you its decision in writing and explain the reasons for it.

• If the independent review organization says yes to part or all of a request for a medical item or service, we must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we receive the independent review organization's decision for standard requests or provide the service within 72 hours from the date we receive the independent review organization's decision for expedited requests.


• If the independent review organization says yes to part or all of a request for a Medicare Part B prescription drug, we must authorize or provide the Medicare Part B prescription drug within 72 hours after we receive the independent review organization's decision for standard requests or within 24 hours from the date we receive the independent review organization's decision for expedited requests.


• If this organization says no to part or all of your appeal, it means they agree with our plan that your request (or part of your request) for coverage for medical care should not be approved. (This is called "upholding the decision" or "turning down your appeal.") In this case, the independent review organization will send you a letter:


• Explaining its decision.


• Notifying you of the right to a Level 3 appeal if the dollar value of the medical care coverage meets a certain minimum. The written notice you get from the independent review organization will tell you the dollar amount you must meet to continue the appeals process.


• Telling you how to file a Level 3 appeal.


• If your Level 2 appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. The details on how to do this are in the written notice you get after your Level 2 appeal.
  
  
  • The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 6 explains the process for Level 3, 4, and 5 appeals.

If your problem is about a service or item Medicaid usually covers:

Step 1: You can ask for an IURO appeal and/or a Fair Hearing with the state.

• Level 2 of the appeals process for services that are usually covered by Medicaid gives you the option to request a review by the state's Independent Utilization Review Organization (IURO), as well as the option to request a Fair Hearing with the state. You must ask for a Fair Hearing in writing or over the phone within 120 calendar days of the date that we sent the decision letter on your Level 1 appeal. The letter you get from us will tell you where to submit your hearing request.

How do I request an IURO appeal?

• The Independent Utilization Review Organization (IURO) is an independent organization that is hired by the State of New Jersey's Department of Banking and Insurance (DOBI). This organization is not connected with us, and it is not a government agency. This organization is chosen by the DOBI to serve as an independent reviewer for medical appeals, and the DOBI administers the IURO appeal process. A review by the IURO is also sometimes called an "IURO appeal" or an "External Appeal".


• The IURO appeal process is optional. You can request an IURO appeal, and wait to receive the IURO's decision, before you request a Fair Hearing. Or, you can request an IURO appeal and a Fair Hearing at the same time (the requests are made to two different organizations). You do not need request an IURO appeal to request a Fair Hearing.


• You can request an IURO appeal yourself, or it can be requested by your Authorized Representative (which includes your provider, if they are acting on your behalf with your written consent).


• You can request an IURO appeal by filling out the External Appeal Application form. A copy of the External Appeal Application form will be sent to you with the decision letter for your Level 1 Appeal. You must send this form to the following address within 60 calendar days of the date on the decision letter for your Level 1 appeal:
  
  Maximus Federal-NJ IHCAP
  3750 Monroe Avenue, Suite 705
  Pittsford, New York 14534


• You may also fax the form to 1-585-425-5296 or email a completed copy of the form to Stateappealseast@maximus.com.


• If you are appealing because we told you we were going to stop or reduce services or items that you were already getting and you want to keep those services or items during your IURO appeal, you must request the IURO appeal within 10 calendar days of the date on the decision letter for your Level 1 appeal.


• If the IURO reviews your case, it will reach a decision within 45 calendar days (or sooner, if your medical condition makes it necessary). If your IURO appeal is a "fast" appeal, the IURO will reach a decision within 48 hours.


• If you have questions about the IURO appeal process and/or need assistance with your application, you can call the New Jersey Department of Banking and Insurance toll­ free at 1-888-393-1062 or 609-777-9470.

How do I request a Fair Hearing?

• You must ask for a Fair Hearing in writing within 120 calendar days of the date that we sent the decision letter on your Level 1 appeal. The letter you get from us will tell you where to submit your hearing request.


• If you ask for an expedited or "fast" Fair Hearing, and you meet all of the requirements for a "fast" hearing, a decision will be made within 72 hours of the agency's receipt of your hearing request.


• If you are appealing because we told you we were going to stop or reduce services or items that you were already getting and you want to keep those services or items during your Fair Hearing, you must request that your benefits be continued in writing on your Fair Hearing request, and you must send your request within 10 calendar days of the date on the decision letter for your Level 1 appeal.

Or, if you asked for an IURO appeal and received a decision before requesting a Fair Hearing, you must send this written request within 10 calendar days of the date on the letter informing you of the decision on your IURO appeal.

Please note that if you ask to have your services or items continue during a Fair Hearing and the final decision is not in your favor, you may be required to pay for the cost of the services or items.

Step 2: The Fair Hearing office gives you their answer.

The Fair Hearing office will tell you their decision in writing and explain the reasons for it.

• If the Fair Hearing office says yes to part or all of a request for a medical item or service, we must authorize or provide the service or item within 72 hours after we receive the decision from the Fair Hearing office.


• If the Fair Hearing office says no to part or all of your appeal, they agree with our plan that your request (or part of your request) for coverage for medical care should not be approved. (This is called "upholding the decision" or "turning down your appeal.")

If the decision is no for all or part of what I asked for, can I make another appeal?

If the independent review organization or Fair Hearing office decision is no for all or part of what you asked for, you have additional appeal rights.

The letter you get from the Fair Hearing office will describe this next appeal option. See Section 6 for more information on your appeal rights after Level 2.

2.5. What if you are asking us to pay you back for a bill you have received for medical care?

If you have already paid for a Medicaid service or item covered by the plan, you can ask our plan to pay you back (paying you back is often called "reimbursing" you). It is your right to be paid back by our plan whenever you've paid for medical services or drugs that are covered by our plan. When you send us a bill you have already paid, we will look at the bill and decide whether the services or drugs should be covered. If we decide they should be covered, we will pay you back for the services or drugs.

Asking for reimbursement is asking for a coverage decision from us.

If you send us the paperwork asking for reimbursement, you are asking for a coverage decision. To make this decision, we will check to see if the medical care you paid for is a covered service. We will also check to see if you followed all the rules for using your coverage for medical care.

If you want us to reimburse you for a Medicare service or item or you are asking us to pay a health care provider for a Medicaid service or item you paid for, you will ask us to make this coverage decision. We will check to see if the medical care you paid for is a covered service. We will also check to see if you followed all the rules for using your coverage for medical care.

• If we say yes to your request: If the medical care is covered and you followed all the rules, we will send you the payment for the cost within 60 calendar days after we receive your request.
• If we say no to your request: If the medical care is not covered, or you did not follow all the rules, we will not send payment. Instead, we will send you a letter that says we will not pay for the services and the reasons why.

If you do not agree with our decision to turn you down, you can make an appeal. If you make an appeal, it means you are asking us to change the coverage decision we made when we turned down your request for payment.

To make this appeal, follow the process for appeals that we describe in Section 1.3. For appeals concerning reimbursement, please note:

• We must give you our answer within 30 calendar days after we receive your appeal. If you are asking us to pay you back for medical care you have already received and paid for, you are not allowed to ask for a fast appeal.


• If the independent review organization decides we should pay, we must send you or the provider the payment within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process after Level 2, we must send the payment you requested to you or to the health care provider within 60 calendar days.

3. Your Part D prescription drugs: How to ask for a coverage decision or make an appeal

3.1. This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug

Your benefits include coverage for many prescription drugs. To be covered, the drug must be used for a medically accepted indication. (Refer to your Evidence of Coverage for more information about a medically accepted indication.)

• This section is about your Part D drugs only . To keep things simple, we generally say "drug" in the rest of this section, instead of repeating "covered outpatient prescription drug" or "Part D drug" every time. We also use the term "drug list" instead of "List of Covered Drugs" or "Formulary."


• If you do not know if a drug is covered or if you meet the rules, you can ask us. Some drugs require that you get approval from us before we will cover it.


• If your pharmacy tells you that your prescription cannot be filled as written, the pharmacy will give you a written notice explaining how to contact us to ask for a coverage decision.

Part D coverage decisions and appeals

A coverage decision is a decision we make about your benefits and coverage. This section tells what you can do if you are in any of the following situations:

• Asking to cover a Part D drug that is not on the plan's List of Covered Drugs. Ask for an exception. Section 3.2.


• Asking to waive a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get). Ask for an exception. Section 3.2.


• Asking to get pre-approval for a drug. Ask for a coverage decision. Section 3.4.


• Pay for a prescription drug you already bought. Ask us to pay you back. Section 3.4.

If you disagree with a coverage decision we have made, you can appeal our decision.

This section tells you both how to ask for coverage decisions and how to request an appeal.

3.2. What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask us to make an "exception." An exception is a type of coverage decision.

For us to consider your exception request, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:

1. Covering a Part D drug for you that is not on our Drug List.


2. Removing a restriction for a covered drug.

3.3. Important things to know about asking for exceptions

Your doctor must tell us the medical reasons

Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.

Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception.

We can say yes or no to your request

• If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true 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.


• If we say no to your request, you can ask for another review by making an appeal.

3.4. Step-by-step: How to ask for a coverage decision, including an exception

Step 1: Decide if you need a "standard coverage decision" or a "fast coverage decision."

"Standard coverage decisions" are made within 72 hours after we receive your doctor's statement. "Fast coverage decisions" are made within 24 hours after we receive your doctor's statement.

If your health requires it, ask us to give you a "fast coverage decision." To get a fast coverage decision, you must meet two requirements:

• You must be asking for a drug you have not yet received. (You cannot ask for fast coverage decision to be paid back for a drug you have already bought.)


• Using the standard deadlines could cause serious harm to your health or hurt your ability to function.


• If your doctor or other prescriber tells us that your health requires a "fast coverage decision," we will automatically give you a fast coverage decision.


• If you ask for a fast coverage decision on your own, without your doctor or prescriber's support, we will decide whether your health requires that we give you a fast coverage decision. If we do not approve a fast coverage decision, we will send you a letter that:
  
  • Explains that we will use the standard deadlines.
  
  
  • Explains if your doctor or other prescriber asks for the fast coverage decision, we will automatically give you a fast coverage decision.
  
  
  • Tells you how you can file a "fast complaint" about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. We will answer your complaint within 24 hours of receipt.

Step 2: Request a "standard coverage decision" or a "fast coverage decision."

Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You can also access the coverage decision process through our website. We must accept any written request, including a request submitted on the CMS Medicare Drug Coverage Request Form (PDF). To assist us in processing your request, please be sure to include your name, contact information, and information identifying which denied claim is being appealed.

You, your doctor, (or other prescriber) or your representative can do this. You can also have a lawyer act on your behalf.

If you are requesting an exception, provide the "supporting statement, which is the medical reasons for the exception. Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary.

Step 3: We consider your request and give you our answer.

Deadlines for a ''fast coverage decision"

• We must generally give you our answer within 24 hours after we receive your request.
  
  
  • For exceptions, we will give you our answer within 24 hours after we receive your doctor's supporting statement. We will give you our answer sooner if your health requires us to.
  
  
  • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization.
• If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor's statement supporting your request.


• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal.

Deadlines for a "standard" coverage decision about a drug you have not yet received

• We must give you our answer within 72 hours after we receive your request.
  
  
  • For exceptions, we will give you our answer within 72 hours after we receive your doctor's supporting. We will give you our answer sooner if your health requires us to.
  
  
  • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization.
  
  
• If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor's statement supporting your request.


• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal.

Deadlines for a "standard" coverage decision about payment for a drug you have already bought

• We must give you our answer within 14 calendar days after we receive your request.
  
  
  • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization
  
  
• If our answer is yes to part or all of what you requested, we are also required to make payment to you within 14 calendar days after we receive your request.


• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal.

Step 4: If we say no to your coverage request, you can make an appeal.

• If we say no, you have the right to ask us to reconsider this decision by making an appeal. This means asking again to get the drug coverage you want. If you make an appeal, it means you are going on to Level 1 of the appeals process.

3.5. Step-by-step: How to make a Level 1 appeal

Step 1: Decide if you need a "standard appeal" or a "fast appeal."

A "standard appeal" is usually made within 7 days. A ''fast appeal" is generally made within 72 hours. If your health requires it, ask for a ''fast appeal"

• If you are appealing a decision we made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a "fast appeal."


• The requirements for getting a "fast appeal" are the same as those for getting a "fast coverage decision" in Section 2.4.

Step 2: You, your representative, doctor or other prescriber must contact us and make your Level 1 appeal. If your health requires a quick response, you must ask for a "fast appeal."

• For standard appeals, submit a written request, or Contact Us


• For fast appeals either submit your appeal in writing or call us at 1-866-892- 8340 (TTY: 711).


• We must accept any written request, including a request submitted on the Medicare Drug Coverage Request Form. Please be sure to include your name, contact information, and information regarding your claim to assist us in processing your request.


• You may submit your appeal electronically through our Request for Redetermination of Medicare Prescription Drug Denial Online Form.


• You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer on the coverage decision. If you miss this deadline and have a good reason for missing it, explain the reason your appeal is late when you make your appeal. We may give you more time to make your appeal. Examples of good cause may include a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.


• You can ask for a copy of the information in your appeal and add more information. You and your doctor may add more information to support your appeal.

Step 3: We consider your appeal and we give you our answer.

• When we are reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information.

Deadlines for a "fast appeal"

• For fast appeals, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to.
  
  
  • If we do not give you an answer within 72 hours, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. Section 3.6 explains the Level 2 appeal process.


• If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appeal.


• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how you can appeal our decision.

Deadlines for a "standard" appeal for a drug you have not yet received

• For standard appeals, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so.
  
  
  • If we do not give you a decision within 7 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. Section 3.6 explains the Level 2 appeal process.


• If our answer is yes to part or all of what you requested, we must provide the coverage as quickly as your health requires, but no later than 7 calendar days after we receive your appeal.


• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how you can appeal our decision.

Deadlines for a "standard appeal" about payment for a drug you have already bought

• We must give you our answer within 14 calendar days after we receive your request.
  
  
  • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization.


• If our answer is yes to part or all of what you requested, we are also required to make payment to you within 30 calendar days after we receive your request.


• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal.

Step 4: If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal.

• If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process.

3.6. Step-by-step: How to make a Level 2 appeal

The independent review organization is an independent organization hired by Medicare. It is not connected with us and is not a government agency. This organization decides whether the decision we made is correct or if it should be changed. Medicare oversees its work.

Step 1: You (or your representative or your doctor or other prescriber) must contact the independent review organization and ask for a review of your case.

• If we say no to your Level 1 appeal, the written notice we send you will include instructions on how to make a Level 2 appeal with the independent review organization. These instructions will tell who can make this Level 2 appeal, what deadlines you must follow, and how to reach the review organization. If, however, we did not complete our review within the applicable timeframe, or make an unfavorable decision regarding "at-risk" determination under our drug management program, we will automatically forward your claim to the IRE.


• We will send the information about your appeal to this organization. This information is called your "case file." You have the right to ask us for a copy of your case file.


• You have a right to give the independent review organization additional information to support your appeal.

Step 2: The independent review organization reviews your appeal.

Reviewers at the independent review organization will take a careful look at all of the information related to your appeal.

Deadlines for "fast appeal"

• If your health requires it, ask the independent review organization for a "fast appeal."


• If the organization agrees to give you a "fast appeal," the organization must give you an answer to your Level 2 appeal within 72 hours after it receives your appeal request.

Deadlines for "standard appeal"

• For standard appeals, the review organization must give you an answer to your Level 2 appeal within 7 calendar days after it receives your appeal if it is for a drug you have not yet received. If you are requesting that we pay you back for a drug you have already bought, the review organization must give you an answer to your Level 2 appeal within 14 calendar days after it receives your request.

Step 3: The independent review organization gives you their answer.

For ''fast appeals":

• If the independent review organization says yes to part or all of what you requested, we must provide the drug coverage that was approved by the review organization within 24 hours after we receive the decision from the review organization.

For "standard appeals":

• If the independent review organization says yes to part or all of your request for coverage, we must provide the drug coverage that was approved by the review organization within 72 hours after we receive the decision from the review organization.


• If the independent review organization says yes to part or all of your request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive the decision from the review organization.

What if the review organization says no to your appeal?

If this organization says no to part or all of your appeal, it means they agree with our decision not to approve your request (or part of your request). (This is called "upholding the decision" or "turning down your appeal.") In this case, the independent review organization will send you a letter:

• Explaining its decision.


• Notifying you of the right to a Level 3 appeal if the dollar value of the drug coverage you are requesting meets a certain minimum. If the dollar value of the drug coverage requesting is too low, you cannot make another appeal and the decision at Level 2 is final.


• Telling you the dollar value that must be in dispute to continue with the appeals process.

Step 4: If your case meets the requirements, you choose whether you want to take your appeal further.

• There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If you want to go on to Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal decision.


• The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 6 tells more about the process for Level 3, 4, and 5 appeals.

4. How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon

When you are admitted to a hospital, you have the right to get all of your covered hospital services that are necessary to diagnose and treat your illness or injury.

During your covered hospital stay, your doctor and the hospital staff will be working with you to prepare for the day when you will leave the hospital. They will help arrange for care you may need.

• The day you leave the hospital is called your "discharge date."


• When your discharge date is decided, your doctor or the hospital staff will tell you.


• If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay and your request will be considered.

4.1. During your inpatient hospital stay, you will get a written notice from Medicare that tells about your rights

Within two days of being admitted to the hospital, you will be given a written notice called "An Important Message from Medicare about Your Rights". Everyone with Medicare gets a copy of this notice.

If you do not get the notice from someone at the hospital (for example, a caseworker or nurse), ask any hospital employee for it. If you need help, Contact Us or 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048).

1. Read this notice carefully and ask questions if you don't understand it. It tells you:

• Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them, and where you can get them.


• Your right to be involved in any decisions about your hospital stay.


• Where to report any concerns you have about the quality of your hospital care.


• Your right to request an immediate review of the decision to discharge you if you think you are being discharged from the hospital too soon. This is a formal, legal way to ask for a delay in your discharge date so that we will cover your hospital care for a longer time.

2. You will be asked to sign the written notice to show that you received it and understand your rights.

• You or someone who is acting on your behalf will be asked to sign the notice.


• Signing the notice shows only that you have received the information about your rights. The notice does not give your discharge date. Signing the notice does not mean you are agreeing on a discharge date.

3. Keep your copy of the notice handy so you will have the information about making an appeal (or reporting a concern about quality of care) if you need it.

• If you sign the notice more than two days before your discharge date, you will get another copy before you are scheduled to be discharged. To look at a copy of this notice in advance, you can Contact Us or 1-800 MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

4.2. Step-by-step: How to make a Level 1 appeal to change your hospital discharge date

If you want to ask for your inpatient hospital services to be covered by us for a longer time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are.

• Follow the process.


• Meet the deadlines.


• Ask for help if you needit. If you have questions or need help at any time, Contact Us . Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance.

During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It checks to see if your planned discharge date is medically appropriate for you.

The Quality Improvement Organizationis a group of doctors and other health care professionals paid by the Federal government to check on and help improve the quality of care for people with Medicare. This includes reviewing hospital discharge dates for people with Medicare. These experts are not part of our plan.

Step 1: Contact the Quality Improvement Organization for your state and ask for an immediate review of your hospital discharge. You must act quickly.

How can you contact this organization?

• The written notice you received (An Important Message from Medicare About Your Rights) tells you how to reach this organization. Or find the name, address, and phone number of the Quality Improvement Organization for your state in your Evidence of Coverage.

Act quickly

• To make your appeal, you must contact the Quality Improvement Organization before you leave the hospital and no later than midnight the day of your discharge.
  
  
  • If you meet this deadline, you may stay in the hospital after your discharge date without paying for it while you wait to get the decision from the Quality Improvement Organization. If you do notmeet this deadline and you decide to stay in the hospital after your planned discharge date, you may have to pay all of the costs for hospital care you receive after your planned discharge date.


• If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to appeal, you must make an appeal directly to our plan instead. For details about this other way to make your appeal, see Section 4.4.

Once you request an immediate review of your hospital discharge the Quality Improvement Organization will contact us. By noon of the day after we are contacted we will give you a Detailed Notice of Discharge. This notice gives your planned discharge date and explains in detail the reasons why your doctor, the hospital, and we think it is right (medically appropriate) for you to be discharged on that date.

You can get a sample of the Detailed Notice of Discharge by calling Member Services or 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY users should call 1-877-486-2048.) Or you can see a sample notice online.

Step 2: The Quality Improvement Organization conducts an independent review of your case.

• Health professionals at the Quality Improvement Organization ("the reviewers") will ask you (or your representative) why you believe coverage for the services should continue. You don't have to prepare anything in writing, but you may do so if you wish.


• The reviewers will also look at your medical information, talk with your doctor, and review information that the hospital and we have given to them.


• By noon of the day after the reviewers told us of your appeal, you will get a written notice from us that gives your planned discharge date. This notice also explains in detail the reasons why your doctor, the hospital, and we think it is right (medically appropriate) for you to be discharged on that date.

Step 3: Within one full day after it has all the needed information, the Quality Improvement Organization will give you its answer to your appeal.

What happens if the answer is yes?

• If the review organization says yes, we must keep providing your covered inpatient hospital services for as long as these services are medically necessary.


• There may be limitations on your covered hospital services.

What happens if the answer is no?

• If the review organization says no, they are saying that your planned discharge date is medically appropriate. If this happens, our coverage for your inpatient hospital services will end at noon on the day after the Quality Improvement Organization gives you its answer to your appeal.


• If the review organization says no to your appeal and you decide to stay in the hospital, then you may have to pay the full cost of hospital care you receive after noon on the day after the Quality Improvement Organization gives you its answer to your appeal.

Step 4: If the answer to your Level 1 appeal is no, you decide if you want to make another appeal.

• If the Quality Improvement Organization has said no to your appeal, and you stay in the hospital after your planned discharge date, then you can make another appeal. Making another appeal means you are going on to "Level 2" of the appeals process.

4.3. Step-by-step: How to make a Level 2 appeal to change your hospital discharge date

During a Level 2 appeal, you ask the Quality Improvement Organization to take another look at their decision on your first appeal. If the Quality Improvement Organization turns down your Level 2 appeal, you may have to pay the full cost for your stay after your planned discharge date.

Step 1: Contact the Quality Improvement Organization again and ask for another review.

• You must ask for this review within 60 calendar days after the day the Quality Improvement Organization said no to your Level 1 appeal. You can ask for this review only if you stay in the hospital after the date that your coverage for the care ended.

Step 2: The Quality Improvement Organization does a second review of your situation.

• Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal.

Step 3: Within 14 calendar days of receipt of your request for a Level 2 appeal, the reviewers will decide on your appeal and tell you their decision.

If the review organization says yes:

• We must reimburse you for the costs of hospital care you have received since noon on the day after the date your first appeal was turned down by the Quality Improvement Organization. We must continue providing coverage for your inpatient hospital care for as long as it is medically necessary.


• Coverage limitations may apply.

If the review organization says no:

• It means they agree with the decision they made on your Level 1 appeal.


• The notice you get will tell you in writing what you can do if you wish to continue with the review process.

Step 4: If the answer is no, you will need to decide whether you want to take your appeal further by going on to Level 3.

• There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If you want to go to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal decision.


• The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 6 tells more about Levels 3, 4, and 5 of the appeals process.

4.4. What if you miss the deadline for making your Level 1 appeal?

You can appeal to us instead

As explained above, you must act quickly to start your Level 1 appeal of your hospital discharge. If you miss the deadline for contacting the Quality Improvement Organization, there is another way to make your appeal.

If you use this other way of making your appeal, the first two levels of appeal are different.

Step-by-Step: How to make a Level 1 Alternate appeal

Step 1: Contact us and ask for a "fast review."

• Ask for a "fast review."This means you are asking us to give you an answer using the "fast" deadlines rather than the "standard" deadlines.

Step 2: We do a "fast" review of your planned discharge date, checking to see if it was medically appropriate.

• During this review, we take a look at all of the information about your hospital stay. We check to see if your planned discharge date was medically appropriate. We see if the decision about when you should leave the hospital was fair and followed all the rules.

Step 3: We give you our decision within 72 hours after you ask for a "fast review".

• If we say yes to your appeal, it means we have agreed with you that you still need to be in the hospital after the discharge date. We will keep providing your covered inpatient hospital services for as long as they are medically necessary. It also means that we have agreed to reimburse you for the costs of care you have received since the date when we said your coverage would end. (There may be coverage limitations that apply.)


• If we say no to your appeal, we are saying that your planned discharge date was medically appropriate. Our coverage for your inpatient hospital services ends as of the day we said coverage would end.
  
  
  • If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you received after the planned discharge date.

Step 4: If we say no to your appeal, your case will automatically be sent on to the next level of the appeals process.

Step-by-Step: Level 2 Alternate appeal Process

The independent review organization is an independent organization hired by Medicare .It is not connected with our plan and is not a government agency. This organization decides whether the decision we made is correct or if it should be changed. Medicare oversees its work.

Step 1: We will automatically forward your case to the independent review organization.

• We are required to send the information for your Level 2 appeal to the independent review organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint.)

Step 2: The independent review organization does a "fast review" of your appeal. The reviewers give you an answer within 72 hours.

• Reviewers at the independent review organization will take a careful look at all of the information related to your appeal of your hospital discharge.


• If this organization says yes to your appeal, then we must pay you back for costs of hospital care you received since the date of your planned discharge. We must also continue the plan's coverage of your inpatient hospital services for as long as it is medically necessary. If there are coverage limitations, these could limit how long we would continue to cover your services.


• If this organization says no to your appeal, it means they agree that your planned hospital discharge date was medically appropriate.
  
  
  • The written notice you get from the independent review organization will tell you how to start a Level 3 appeal, which is handled by an Administrative Law Judge or attorney adjudicator.

Step 3: If the independent review organization turns down your appeal, you choose whether you want to take your appeal further.

• There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If reviewers say no to your Level 2 appeal, you decide whether to accept their decision or go on to Level 3 appeal.


• Section 6 tells more about the process for Level 3, 4, and 5 appeals.

5. How to ask us to keep covering certain medical services if you think your coverage is ending too soon

5.1. This section is only three services: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services

When you are getting home health services, skilled nursing care, or rehabilitation care (Comprehensive Outpatient Rehabilitation Facility), you have the right to keep getting your covered services for that type of care for as long as the care is needed to diagnose and treat your illness or injury.

When we decide it is time to stop covering any of the three types of care for you, we are required to tell you in advance. When your coverage for that care ends, we will stop paying for your care.

If you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask for an appeal.

5.2. We will tell you in advance when your coverage will be ending

1. You receive a notice in writing at least two days before our plan is going to stop covering your care. The notice tells you:
   
   
   • The date when we will stop covering the care for you.
   
   
   • How to request a "fast track appeal" to request us to keep covering your care for a longer period of time.


2. You, or someone who is acting on your behalf, will be asked to sign the written notice to show that you received it. Signing the notice shows only that you have received the information about when your coverage will stop. Signing it does not mean you agree with the plan's decision to stop care.

5.3. Step-by-step: How to make a Level 1 appeal to have our plan cover your care for a longer time

If you want to ask us to cover your care for a longer period of time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are.

• Follow the process.


• Meet the deadlines.


• Ask for help if you need it.If you have questions or need help at any time, Contact Us . Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance.

During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It decides if the end date for your care is medically appropriate.

The Quality Improvement Organizationis a group of doctors and other health care experts paid by the Federal government to check on and help improve the quality of care for people with Medicare. This includes reviewing plan decisions about when it's time to stop covering certain kinds of medical care. These experts are not part of our plan.

Step 1: Make your Level 1 appeal: contact the Quality Improvement Organization and ask for a fast-track appeal. You must act quickly.

How can you contact this organization?

• The written notice you received (Notice of Medicare Non-Coverage) tells you how to reach this organization. Or find the name, address, and phone number of the Quality Improvement Organization for your state in Chapter 2 of your Evidence of Coverage.

Act quickly:

• You must contact the Quality Improvement Organization to start your appeal by noon of the day before the effective date on the Notice of Medicare Non-Coverage.

Your deadline for contacting this organization.

• If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to file an appeal, you must make an appeal directly to us instead. For details about this other way to make your appeal, see Section 5.5.

Step 2: The Quality Improvement Organization conducts an independent review of your case.

What happens during this review?

• Health professionals at the Quality Improvement Organization ("the reviewers") will ask you, or your representative, why you believe coverage for the services should continue. You don't have to prepare anything in writing, but you may do so if you wish.


• The review organization will also look at your medical information, talk with your doctor, and review information that our plan has given to them.


• By the end of the day the reviewers told us of your appeal, you will get the Detailed Explanation of Non-Coverage from us that explains in detail our reasons for ending our coverage for your services.

Step 3: Within one full day after they have all the information they need, the reviewers will tell you their decision.

What happens if the reviewers say yes?

• If the reviewers say yes to your appeal, then we must keep providing your covered services for as long as it is medically necessary.


• There may be limitations on your covered services.

What happens if the reviewers say no?

• If the reviewers say no, then your coverage will end on the date we have told you.


• If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services afterthis date when your coverage ends, then you will have to pay the full cost of this care yourself.

Step 4: If the answer to your Level 1 appeal is no, you decide if you want to make another appeal.

• If reviewers say no to your Level 1 appeal and you choose to continue getting care after your coverage for the care has ended, then you can make a Level 2 appeal.

5.4. Step-by-step: How to make a Level 2 appeal to have our plan cover your care for a longer time

During a Level 2 appeal, you ask the Quality Improvement Organization to take another look at the decision on your first appeal. If the Quality Improvement Organization turns down your Level 2 appeal, you may have to pay the full cost for your home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services afterthe date when we said your coverage would end.

Step 1: Contact the Quality Improvement Organization again and ask for another review.

• You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended.

Step 2: The Quality Improvement Organization does a second review of your situation.

• Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal.

Step 3: Within 14 days of receipt of your appeal request, reviewers will decide on your appeal and tell you their decision.

What happens if the review organization says yes?

• We must reimburse you for the costs of care you have received since the date when we said your coverage would end. We must continue providing coverage for the care for as long as it is medically necessary.


• There may be coverage limitations that apply.

What happens if the review organization says no?

• It means they agree with the decision made to your Level 1 appeal.


• The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by an Administrative Law Judge or attorney adjudicator.

Step 4: If the answer is no, you will need to decide whether you want to take your appeal further.

• There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If you want to go on to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal decision.


• The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 6 tells more about the process for Level 3, 4, and 5 appeals.

5.5. What if you miss the deadline for making your Level 1 appeal?

You can appeal to us instead

As explained above, you must act quickly to contact the Quality Improvement Organization to start your first appeal (within a day or two, at the most). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different.

Step-by-step: How to make a Level 1 Alternate appeal

Step 1: Contact us and ask for a "fast review."

• Ask for a "fast review."This means you are asking us to give you an answer using the "fast" deadlines rather than the "standard" deadlines. Step 2: We do a "fast" review of the decision we made about when to end coverage for your services.


• During this review, we take another look at all of the information about your case. We check to see if we were following all the rules when we set the date for ending the plan's coverage for services you were receiving.

Step 3: We give you our decision within 72 hours after you ask for a "fast review".

• If we say yes to your appeal, it means we have agreed with you that you need services longer, and we will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for the costs of care you have received since the date when we said your coverage would end. (There may be coverage limitations that apply.)


• If we say no to your appeal, then your coverage will end on the date we told you and we will not pay the costs after this date.


• If you continued to get home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services afterthe date when we said your coverage would end, then you will have to pay the full cost of this care.

Step 4: If we say no to your fast appeal, your case will automatically go on to the next level of the appeals process.

Step-by-step: Level 2 Alternate appeal Process

During the Level 2 appeal, the independent review organization reviews the decision we made to your "fast appeal." This organization decides whether the decision should be changed. The independent review organization is an independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the independent review organization. Medicare oversees its work.

Step 1: We automatically forward your case to the independent review organization.

• We are required to send the information for your Level 2 appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint.)

Step 2: The independent review organization does a "fast review" of your appeal. The reviewers give you an answer within 72 hours.

• Reviewers at the independent review organization will take a careful look at all of the information related to your appeal.


• If this organization says yes to your appeal, then we must pay you back for costs of care you have received since the date when we said your coverage would end. We must also continue to cover the care for as long as it is medically necessary. If there are coverage limitations, these could limit how long we would continue to cover services.


• If this organization says no to your appeal, it means they agree with the decision our plan made to your first appeal and will not change it.
  
  
  • The notice you get from the independent review organization will tell you in writing what you can do if you wish to go on to a Level 3 appeal.

Step 3: If the independent review organization says no to your appeal, you choose whether you want to take your appeal further.

• There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If you want to go on to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal decision.


• A Level 3 appeal is reviewed by an Administrative Law Judge or attorney adjudicator. Section 6 tells more about the process for Level 3, 4, and 5 appeals.

6. Taking your appeal to Level 3 and beyond

6.1. Appeal Levels 3, 4 and 5 for Medical Service Requests

This section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal, and both of your appeals have been turned down.

If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. The written response you receive to your Level 2 appeal will explain how to make a Level 3 appeal.

For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels.

Level 3 appeal: An Administrative Law Judge or an attorney adjudicator who works for the Federal government will review your appeal and give you an answer.

• If the Administrative Law Judge or attorney adjudicator says yes to your appeal, the appeals process may or may not be over. Unlike a decision at a Level 2 appeal, we have the right to appeal a Level 3 decision that is favorable to you. If we decide to appeal it will go to a Level 4 appeal.
  
  
  • If we decide not to appeal, we must authorize or provide you with the service within 60 calendar days after receiving the Administrative Law Judge's or attorney adjudicator's decision.
  
  
  • If we decide to appeal the decision, we will send you a copy of the Level 4 appeal request with any accompanying documents. We may wait for the Level 4 appeal decision before authorizing or providing the service in dispute.


• If the Administrative Law Judge or attorney adjudicator says no to your appeal, the appeals process may or may not be over.
  
  
  • If you decide to accept this decision that turns down your appeal, the appeals process 1s over.
  
  
  • If you do not want to accept the decision, you can continue to the next level of the review process. The notice you get will tell you what to do for a Level 4 appeal.

Level 4 appeal: The Medicare Appeals Council (Council) will review your appeal and give you an answer. The Council is part of the Federal government.

• If the answer is yes, or if the Council denies our request to review a favorable Level 3 appeal decision, the appeals process may or may not be over. Unlike a decision at Level 2, we have the right to appeal a Level 4 decision that is favorable to you. We will decide whether to appeal this decision to Level 5.
  
  
  • If we decide notto appeal the decision, we must authorize or provide you with the service within 60 calendar days after receiving the Council's decision.
  
  
  • If we decide to appeal the decision, we will let you know in writing.


• If the answer is no or if the Council denies the review request, the appeals process may or may not be over.


• If you decide to accept this decision that turns down your appeal, the appeals process 1s over.
  
  
  • If you do not want to accept the decision, you may be able to continue to the next level of the review process. If the Council says no to your appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 appeal and how to continue with a Level 5 appeal.

Level 5 appeal: A judge at the Federal District Court will review your appeal.

• A judge will review all of the information and decide yes or no to your request. This is a final answer. There are no more appeal levels after the Federal District Court.

6.2. Additional Medicaid appeals

You also have other appeal rights if your appeal is about services or items that Medicaid usually covers. The letter you get from the Fair Hearing office will tell you what to do if you wish to continue the appeals process.

6.3. Appeal Levels 3, 4 and 5 for Part D Drug Requests

This section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal, and both of your appeals have been turned down.

If the value of the drug you have appealed meets a certain dollar amount, you may be able to go on to additional levels of appeal. If the dollar amount is less, you cannot appeal any further. The written response you receive to your Level 2 appeal will explain who to contact and what to do to ask for a Level 3 appeal.

For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels.

Level 3 appeal: An Administrative Law Judge or attorney adjudicator who works for the Federal government will review your appeal and give you an answer.

• If the answer is yes, the appeals process is over. We must authorize or provide the drug coverage that was approved by the Administrative Law Judge or attorney.

Redeterminations (Part D Appeals)

If we deny your request for a coverage determination (exception), or a payment for a drug, you, your doctor, or your representative may ask us for a redetermination. You have 60 days from the date of our coverage denial letter to request a redetermination. You can complete the Redetermination form, but you do not have to use it.

You can ask for a drug coverage redetermination one of the following ways:

• Online: Complete our online Request for Redetermination of Medicare Drug Denial (Part D appeal) form.
• Drug Coverage Redetermination Form: Request for Redetermination of Prescription Drug Denial (PDF)
  • This form can also be found on your plan's Pharmacy page.
• Write:
  • Wellcare, Medicare Pharmacy Appeals
    P.O. Box 31383
    Tampa, FL 33631-3383
• Fax: 1-866-388-1766
• Phone: Contact Us.

An expedited redetermination (Part D appeal) request can also be made by phone at Contact Us.

If you or your doctor states that waiting 7 days for a standard decision could seriously harm your health or ability to regain maximum function, you can ask for a fast (expedited) decision. If your doctor states this, we will automatically give you a decision within 72 hours. If we do not receive your doctor’s supporting statement for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

For more information about coverage determinations (exceptions) and redeterminations (Part D appeals), please refer to your Evidence of Coverage (EOC).