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GLOBALHEALTH APPEALS, GRIEVANCES, AND COVERAGE DETERMINATIONS

GlobalHealth allows members to submit complaints, which may become either an appeal or a grievance, to the plan.

Part C Organization Determinations, Appeals, and Grievances

This section is about your benefits for medical care or treatment or services. For information about your Part D prescription drugs, click here.

Request for an Organization Determination

You have the right to ask the plan to provide or pay for items or services you think should be covered, provided, or continued. This is called an "organization determination." You, your representative, or your doctor can request an organization determination from the plan by mailing your written request along with any supporting documentation to:

GlobalHealth
c/o Medical Management - Organization Determination
P.O. Box 1747
Oklahoma City, OK 73101-1747 
Or via Fax: 405-280-2960

This request can also be made over the phone by calling (844) 280-5555 (TTY users call 711), 8:00 AM and 8:00PM, 7 days a week October 1 - March 31, or 8:00 AM to 8:00 PM Monday through Friday April 1 - September 30. The standard time frame for this decision is 14 calendar days.

You may request that the plan expedite (fast-review) organization determination when you believe that waiting for a decision under the standard time frame could place your life, health, or ability to regain maximum function in serious jeopardy. If the organization determination request includes but is not limited to one of the following key words it will be considered for an expedited organization determination: Expedited, Fast, STAT, Urgent, ASAP, Rush, Immediate, Life Threatening. A fast decision can be requested over the phone by calling (844) 280-5555 or in writing along with supporting documentation to:

GlobalHealth
c/o Medical Management - Organization Determination
P.O. Box 1747
Oklahoma City, OK 73101-1747 
Or via Fax: 405-280-2960

The plan must notify you of its decision within 72 hours of receipt if it determines, or your doctor tells the plan, that your life or health may be seriously harmed waiting for a standard decision.

What is an Appeal?

The process that enables independent review of adverse organization determinations.

Per Medicare, an appeal is any procedure that deals with the review of adverse organization determinations on the healthcare services a member believes he or she is entitled to receive, including delay in providing, arranging for, or approving the healthcare services (such that a delay would adversely affect the health of the member), or on any amounts the member must pay for a service. These procedures include reconsideration by the plan and if the plan upholds (partially or fully) its adverse decision (denial), consideration by an Independent Review Entity (IRE), hearings before Administrative Law Judges (ALJs), review by the Medicare Appeals Council (MAC), and judicial review.

What is the Appeal Process?

If the plan won’t cover the items or services you asked for, the plan must tell you in writing why it won't provide or pay for the items or services and how to appeal this decision. You will get a notice explaining why the plan fully or partially denied your request and instructions on how to appeal the plan’s decision. If you appeal the plan’s decision, you may want to ask for a copy of your file containing medical and other information about your case.

If you disagree with the organization determination (the plan’s initial decision) you can file an appeal.

Standard Appeal

For a standard (post-service request for payment) appeal, you may submit a written request, along with supporting documentation to:

GlobalHealth
c/o Appeals and Grievances
P.O. Box 1747
Oklahoma City, OK 73101-1747
Or via Fax: 405-280-2960

You may submit a request by telephone by calling Customer Care.

Expedited Appeal

If your health requires a quick response, you must ask for a "Fast Appeal," sometimes called "Expedited Appeal". You may request that the plan expedite an appeal when you believe that waiting for a decision under the standard time frame could place your life, health, or ability to regain maximum function in serious jeopardy. If the appeal request includes but is not limited to one of the following key words it will be considered for an expedited appeal: Expedited, Fast, STAT, Urgent, ASAP, Rush, Immediate, Life Threatening. A fast decision can be requested over the phone by calling (844) 280-5555 or in writing along with supporting documentation to:

GlobalHealth
c/o Appeals and Grievances
P.O. Box 1747
Oklahoma City, OK 73101-1747
Or via Fax: 405-280-2960

Additional Appeal Levels

The Medicare Advantage appeals process has up to five appeal levels. If you disagree with the decision made at any level of the process, you can generally go to the next level depending on the amount in controversy. At each level, you will be given instructions on how to move to the next level of appeal.

What is a Grievance?

A complaint or dispute that describes a member's dissatisfaction with the way the plan provides healthcare services, regardless of whether a remedy exists.

Per Medicare, a grievance is any complaint or dispute, other than one involving an organization determination, expressing dissatisfaction with the manner in which the plan or delegated entity provides healthcare services, regardless of whether any remedial action can be taken. A member or his or her representative may make the complaint or dispute, either orally or in writing, to the plan. An expedited grievance may also include a complaint that the plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame.

In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of healthcare. If a member or his or her representative is dissatisfied with the services provided, such as sales, enrollment, or service processes, they have the right to file a grievance with the plan. The plan will review the grievance, take necessary action, and notify the member or his or her representative. A grievance does not involve an appeal.

Expedited Grievance

You may file an expedited grievance orally or in writing should you disagree with our decision not to conduct an expedited organization/coverage determination or an expedited reconsideration/redetermination. You may also file an expedited grievance if you disagree with the plan’s decision to request a fourteen (14) calendar day extension to make a decision on an organization determination, coverage determination, or reconsideration. The plan will respond to your expedited grievance within 24 hours.

You may request an expedited grievance by contacting Customer Care at (844) 280-5555. Value-added items and services included with the plan do not have appeal rights; however, members may file grievances regarding value-added items and services received. For more information about the Appeals and Grievances process, please refer to the Appeals & Grievances Chapter in your Evidence of Coverage, for more information on what to do next.

You may submit your complaint in writing to the plan to the following address:

GlobalHealth
c/o Appeals and Grievances
P.O. Box 1747
Oklahoma City, OK 73101-1747
Or via Fax: 405-280-2960

You may also call and file a complaint with Medicare at (800) 633-4227, TTY users should call (877) 486-2048, 24 hours a day/7 days a week or visit www.Medicare.gov or the Ombudsman at Medicare for more information (by clicking on these links you will be leaving our website).

To submit an organizational determination, appeal and/or grievance orally, or for more information about organizational determinations, appeals and grievances processes, or to check on the status, please contact us at (844) 280-5555 (TTY users call 711). You can find more information about what your plan covers in your Evidence of Coverage.

If you wish to request an aggregate number of grievances, appeals and exceptions filed with GlobalHealth or for process/status questions, contact us at (844) 280-5555 (TTY users call 711). Please refer to your Evidence of Coverage on Complaints in Chapter 2, Section 1 for more information on what to do next.

Appointing a Representative

As our member, you can appoint a caregiver or someone to act as an official representative on your behalf. We must have your written authorization signed by both you and the person you wish to designate as your Appointed Representative.

A representative who is appointed by the court or who is otherwise authorized under state law to act on your behalf in this regard may also file a request on your behalf, after sending us the supporting legal documentation. You will not need to complete an Appointment of Representative Form if you send supporting documentation with your request showing that another person is authorized to act on your behalf under state law.

Click here for the form.

GRIEVANCES AND APPEALS FOR PART D DRUGS

Part D Coverage Decisions, Exceptions, and Appeals

What is a coverage decision?

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. An initial coverage decision about your Part D drugs is called a coverage determination.

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. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.

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. If you ask us for a tiering exception we will generally not approve your request for an exception unless all the alternative drugs in the lower cost-sharing tier(s) won't work as well for you.

For more detailed information and examples of exceptions, please review the Evidence of Coverage.

How do I ask for a coverage determination, including an exception?

Start by calling, writing or faxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this. You can also access the coverage decision process through online. For more detailed information and examples of exceptions, please review the Evidence of Coverage.

Coverage Determination (initial request)

Phone:
(866) 494-3927 (TTY users call 711)
24 hours a day, seven days a week
Fax: 1-855-633-7673

Mail:
CVS Caremark Part D Services
Appeals Dept., MC109
P.O. Box 52000
Phoenix, AZ 85072-2000

Online: Initiate coverage determination request here.

Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. If your health requires it ask us to give you a "fast coverage decision". You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

If we approve your request, depending on the drug, most formulary exceptions are granted for a minimum of one year beginning on the date the formulary exception was originally approved.

If we say no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made. An appeal to the plan about a Part D drug coverage decision is called a plan "redetermination."

Contact us to request an appeal (Redetermination).

Phone:
(866) 494-3927 (TTY users call 711)
24 hours a day, seven days a week

Fax: 1-855-633-7673

Mail:
CVS Caremark Part D Services
Appeals Dept., MC109
P.O. Box 52000
Phoenix, AZ 85072-2000

Online: Initiate redetermination request here. 

We must give you our answer within seven days after we receive your request for a standard Appeal. If your health requires an answer sooner than seven days, you may ask for a fast Appeal (also called an expedited Appeal). For a fast Appeal, we must give you our answer within 72 hours after we receive your appeal (or your prescriber’s supporting statement).

If we approve your request, depending on the drug, most formulary exceptions are granted for a minimum of one year beginning on the date the formulary exception was originally approved.

Additional Appeal Levels

Please refer to your Evidence of Coverage sections on Coverage Decisions and Exceptions for more information on what to do next if you disagree with the decision made at any level in the process. The appeals process has up to five levels of appeals.

For an aggregate number of coverage determinations/appeals or for process or status questions, please contact us at (866) 494-3927.

What is a Grievance?

A Grievance is a complaint you file for any other problem or issue with GlobalHealth or one of our network pharmacies. You have the right to file a Grievance at any time.

How do I file a Grievance with GlobalHealth?

If you have a Grievance or a question about Grievances, we encourage you to first call us at (866) 494-3927 (TTY users call 711). We will try to resolve any complaint that you might have over the phone.

If you request a written response to your phone complaint, we will respond to you in writing. If we cannot resolve your complaint over the phone, we will resort to using a formal procedure to review your complaints. We call this the GlobalHealth Grievance Process.

You may file a Grievance by telephone, fax, or through the mail, no later than 60 days after the event that caused the Grievance. We will respond to all written Grievances no later than 30 days from the date GlobalHealth received the Grievance.

If your Grievance involves a refusal by GlobalHealth to grant your request for an expedited Coverage Determination or an Expedited Redetermination, and you have not yet received the medication that is in dispute, you may file an expedited (fast) Grievance. To file an expedited Grievance, please contact us at (866) 494-3927 (TTY users call 711) to make a request over the phone. This number is answered by a live agent 24 hours a day, seven days a week. In this case, you will receive a response within 24 hours.

You can file a Grievance or Expedited Grievance by mailing or faxing us your written complaint to:

CVS Caremark
Medicare Part D Grievance Department
P.O. Box 30016
Pittsburgh PA 15222-0330
Fax: 1-855-633-7673

Most complaints are answered within 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. You will receive a letter notifying you of the extension.

Please refer to the Chapter on Grievances in your Evidence of Coverage, for more information on what to do next.

For an aggregate number of grievances or for process or status questions, please contact us at:

Part D Grievances:
(866) 494-3927 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 711) 7 days a week.

You may also file a complaint with Medicare by calling (800) 633-4227 (TTY users call (877) 486-2048) 24 hours a day, 7 days a week or visit the Medicare website. On this site you may file a complaint using the Medicare Complaint Form. (by clicking on these links you will be leaving our website)

Appointing a Representative

As our member, you can appoint a caregiver or someone to act as an official representative on your behalf. We must have your written authorization signed by both you and the person you wish to designate as your Appointed Representative.

A representative who is appointed by the court or who is otherwise authorized under state law to act on your behalf in this regard may also file a request on your behalf, after sending us the supporting legal documentation. You will not need to complete an Appointment of Representation Form if you send supporting documentation with your request showing that another person is authorized to act on your behalf under state law.