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Part D Grievances and Appeals / Coverage Determinations

WHAT IS A PART D APPEAL?

You may request an ‘appeal’ when you are dissatisfied with the decision the plan has made about a coverage determination review. An appeal is a formal way of asking us to review and change a coverage determination we have made.

There are five levels to the appeals process:

  • First Level: Redetermination by the Medicare Advantage Part D (MA-PD) Sponsor
  • Second Level: Redetermination by an Independent Review Entity (IRE)
  • Third Level: Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals
  • Fourth Level: Review by the Medicare Appeals Council (MAC)
  • Fifth Level: Judicial Review in Federal District Court

WHAT IS A PART D REDETERMINATION?

If Simply Healthcare Plans issues an adverse coverage determination, the enrollee, the enrollee's prescriber, or the enrollee's representative may appeal the decision to the plan by requesting a standard or expedited redetermination.

How to Request a Redetermination

Redetermination requests must be filed with the plan within 60 calendar days from the date of the notice of the coverage determination.

  • Standard or expedited requests may be made verbally or in writing

How Simply Healthcare Plans Processes Redetermination Requests

Once the request is received by the plan, a decision is made and notice is provided as quickly as your health requires, but no later the 72 hours for expedited requests or 7 calendar days for standard requests.

If the decision is unfavorable, the decision will contain the information you need to file a request for a reconsideration by the Independent Review Entity.

If you or your representative requires assistance with reconsiderations please call Member Services toll-free at 1-877-577-0115 (TTY 711). From October 1 thru February 14, our hours of operations are 8 a.m. – 8 p.m., EST 7 days a week. From February 15 until September 30, our hours of operations are Monday thru Friday, 8 a.m. – 8 p.m. EST.

You may submit your request to the plan's Grievance and Appeals Department at the following address, telephone number or fax:

Simply Healthcare Plans
Attn: Grievance and Appeals Department
9250 W. Flagler Street, Suite 600
Miami, FL 33174-3460
Call: 1-877-577-0115 (TTY 711)
Fax number: 1-866-887-8943
 

WHAT IF I HAVE A PROBLEM WITH MY PRESCRIPTION DRUG COVERAGE?

If you have an issue with your prescription drug coverage, you may file a grievance with the plan. A grievance is any complaint, other than one that involves a coverage determination.

You or your legal representative may file a grievance with the plan verbally or in writing. A grievance must be filed within 60 calendar days after the event or incident that led to your grievance.

The plan must notify you of its decision about your grievance as quickly as your health status requires, but no later than 30 calendar days after receiving your complaint. In some cases, the plan may extend the timeframe by up to 14 calendar days if you request the extension, or if the plan justifies a need for additional information and the delay is in your best interest.

We must respond to a grievance within 24 hours if:

  1. The grievance involves a refusal by the plan to grant your request for an expedited coverage determination or expedited redetermination, and
  2. You have not yet purchased or received the drug that is in dispute.

If you call the Member Services Department the plan will try to resolve any complaint you might have over the phone.

You may submit your request to the plan's Grievance and Appeals Department at the following address or fax:

Simply Healthcare Plans, Inc.
Attn: Grievance and Appeals Department
9250 W. Flagler Street, Suite 600
Miami, FL 33174-3460
Call: 1-877-577-0115 (TTY 711)
Fax number: 1-866-887-8943
 
Redetermination Request Form

PART D COVERAGE DETERMINATIONS & EXCEPTIONS

When Simply Healthcare makes a decision whether or not to provide or pay for a Part D drug, it’s called a Coverage Determination.

There are “exceptions” for some Coverage Determination decisions, including:

  • A “formulary exception” – When you believe you need a drug that is not on the plan's formulary
  • A “tiering exception” – When you believe you should get your drug at a lower cost share

All exception requests must be supported by a statement by the prescribing physician. Standard Coverage Determinations will be made within 72 hours. Expedited Coverage Determinations will be made within 24 hours.

How to Request a Coverage Determination

If you or your representative require assistance with Coverage Determinations please call Member Services toll-free at 1-877-577-0115 (TTY 711). From October 1 thru February 14, our hours of operations are 8 a.m. – 8 p.m., EST., 7 days a week. From February 15 until September 30, our hours of operations are Monday thru Friday, 8 a.m. – 8 p.m. EST.

You may submit your request to the plan's Pharmacy Department at the following address or fax:

Simply Healthcare Plans, Inc.
Attn: Pharmacy Department
9250 W. Flagler Street, Suite 600
Miami, FL 33174-3460
Call: 1-877-577-0115 (TTY 711)
Fax number: 1-866-887-8943
 
 

Request for Medicare Prescription Drug Coverage Determination (English / Spanish)

You, your appointed representative, or your provider may request a Coverage Determination or exception by completing the Request for Medicare Part D Coverage Determination Form.
For access to your plan's Evidence of Coverage, click here.

EXCEPTIONS

An exception request is type of coverage determination that you, your physician or other legal representative may request. Exception requests are granted when we determine that the requested drug is medically necessary for you. Therefore your physician must submit a supporting statement to the plan explaining the reason for the request.

There are different types of exceptions, such as:

  • Tiering exceptions
  • Formulary exceptions

Your physician may submit his/her statement by:

  1. Calling the Simply Healthcare Pharmacy Department at 1-877-577-9044 (TTY: 711) from 8 a.m. to 8 p.m. EST; Monday - Friday; or
  2. Faxing a statement to the Pharmacy department at 1-866-887-8943; or
  3. Mailing a statement to : Simply Healthcare, 9250 W. Flagler Street, Suite 600, Miami, FL 33174-3460, Attn: Pharmacy Department

Once your request has been processed, you and your physician will be notified.

Appointment of Representative

For instructions and access to the CMS Appointment of Representation Form (Form CMS-1696), click on the link below:

Instructions on how to Appoint a Representative - English
Appointment of Representative Form - English

Instructions on how to Appoint a Representative - Spanish
Appointment of Representative Form - Spanish 

Last Updated: 
November 1, 2017