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SD Grievances and Appeals for Part D

Grievances and Appeals for Part D

Member appeals and grievances process

Senior Dimensions

Coverage determinations

A coverage determination is the initial decision we make about whether or not to cover a Part D drug you've requested or to pay for a Part D drug you've already received. When we give you our decision, we will use the standard deadlines unless we have agreed to use the fast deadlines or your doctor has requested a fast decision. A standard decision means we will give you an answer within seventy-two (72) hours after we receive your doctor's statement. A fast decision means we will answer within twenty-four (24) hours.

Exceptions

An exception is a type of coverage determination. You, your doctor or other prescriber may ask us to make an exception to our Part D coverage rules in a number of situations. For example, you can ask us to cover a drug which is not on our drug list. If we approve your request to cover a drug which is not on our drug list, you may not request an exception to the drug's copay or coinsurance amount.

Or you can ask us to provide a higher level of coverage (pay more) for your drug. Generally, we will approve your request for a higher level of coverage only if the Part D drug we do cover at that level would not be as effective in treating your condition or would cause harmful side effects.

Your doctor or other prescriber must submit a statement supporting your exception request. For a quicker decision, this supporting statement should be sent with the exception request. You should make any exception requests before you try to fill your prescription at a pharmacy.

What is an appeal?

An appeal is any of the procedures that deal with the review of adverse coverage determinations made by the Part D plan sponsor on the benefits under a Part D plan the enrollee believes he or she is entitled to receive, including a delay in providing or approving the drug coverage (when a delay would adversely affect the health of the enrollee), or on any amounts the enrollee must pay for the drug coverage.

When can I file an appeal?

You may file an appeal within sixty (60) calendar days from the date of the initial coverage determination, or within sixty (60) days of the Health Plan's written notice that a payment was not made. The deadline may be extended if you have a valid reason for missing it. In your written appeal, explain why you missed the deadline.

Can someone file an appeal for me?

Yes, someone else can file an appeal on your behalf. If someone files an appeal on your behalf, you must appoint the individual to act as your representative. To name another person as your representative to request an appeal, contact Customer Service toll-free at 1-800-650-6232, TTY 711 to request an Appointment of Representation (AOR) form. Customer Service hours: October 1 - February 14: 8 a.m. - 8 p.m. local time, 7 days a week. February 15 - September 30: 8 a.m. - 8 p.m. local time, Monday - Friday. On Saturday, Sunday and holidays, please leave a detailed message and a representative will return your call within one business day. You may obtain a copy of the AOR form online 24 hours a day by clicking here (Published August 1, 2018). The form must be completed, signed by you and the person you would like to act on your behalf and returned to:

Part D appeals
P.O. Box 6106
CA124-0197
Cypress, CA 90630

or

Standard appeal-Fax: 1-866-308-6294

Expedited appeal-Fax: 1-866-308-6296

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 to:

Part D appeals
P.O. Box 6106
CA124-0197
Cypress, CA 90630

or

Standard appeal-fax: 1-866-308-6294

Expedited appeal-fax: 1-866-308-6296

The Health Plan processes all requests for appeals according to the following time frames:

  • Standard appeal: within seven (7) calendar days of receipt of the request
  • Expedited appeal: within seventy-two (72) hours of receipt of the request

You may submit your request in writing to the above address or contact Customer Service toll-free at 1-800-650-6232, TTY 711 to file an expedited/fast appeal. If it is outside of Customer Service business hours to request an expedited review or fast appeal, please fax request to 1-866-308-6296.

Fast appeals (expedite)

You may request and receive a fast decision on your appeal if waiting for a decision to be made in the standard time frame could seriously harm your health or your ability to function. If your doctor gives us a supporting statement in writing or verbally, we will automatically give you a fast appeal. A decision will be made as soon as possible but no later than seventy-two (72) hours after we receive your request.

The Center for Medicaid & Medicare Services (CMS) does not allow extensions to the Part D appeal time frames.

Note: Fast appeals do not include payment reconsideration requests for a drug you have already received.

Part D drug grievances

If you get Medicare Part D prescription drug coverage through our plan, you have the right to file a grievance.

If you have a complaint, you or your representative may call the phone number for Medicare Part D grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. We will try to resolve your complaint over the phone.

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

If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints:

Submit a written request for a grievance to:

Health Plan of Nevada, Inc.
Senior Dimensions
P.O. Box 14865
Las Vegas, NV 89114-5645

or

Fax: 702-266-8813

The grievance must be submitted within sixty (60) days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than thirty (30) days after receiving your complaint.

We may extend the time frame by up to fourteen (14) days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.

Fast grievances

If you disagree with our decision not to expedite your request for a coverage determination or redetermination, you may request an expedited or "fast" grievance. We will respond to your request for a fast grievance within twenty-four (24) hours of receipt.

You may submit a written request for a fast grievance to:

Health Plan of Nevada, Inc.
Senior Dimensions
P.O. Box 14865
Las Vegas, NV 89114-5645

or

Fax: 702-266-8813

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

You can also review your Evidence of Coverage for appeals and grievance information. To access your Evidence of Coverage from this website, click here. Appeals and grievance information is listed under Chapter 9 of the Evidence of Coverage. For information on how to obtain an aggregate number of appeals, grievances, and exceptions filed with the plan, please contact Customer Service.

If you have questions or would like to inquire about the status of an appeal, you or your provider may call Senior Dimensions toll-free at 1-800-650-6232, TTY 711. If you are calling outside of Customer Service business hours to request an expedited/fast grievance, please fax request to 702-266-8813.

Find out how to appoint a representative.