Coverage Decision, Appeals & Grievance Information (HMO)

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 medical services or drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision.

What is an Appeal?

An appeal is something you do if you disagree with our decision to deny a request for coverage of health care services, prescription drugs, payment for services or drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are receiving. An appeal is a formal way of asking us to review and change a coverage decision we have made.

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.

What is an Organization Determination?

An organization determination is any decision (an approval or denial) made by a Medicare health plan (The Health Plan) regarding:

1. Receipt of, or payment for, a managed care item or service;
2. The amount a health plan requires and enrollee to pay for an item or service; or
3. A limit of the quantity of items or services.

An enrollee or an enrollee's representative, or any provider that furnishes, or intends to furnish services to an enrollee may request a standard organization determination by filing a request with their health plan, The Health Plan. Expedited requests may be requested by an enrollee, an enrollee's representative, or any physician, regardless of whether the physician is affiliated with the health plan.

Once an organization determination has occurred, the appeals process is available if the enrollee believes the Medicare health plan's (The Health Plan) decision is unfavorable. If a managed care enrollee does not agree with the organization determination, the case must be handled using the mandated appeals process. Please see information below regarding the appeals process.

If you wish to appoint a representative to act on your behalf, you can do so by completing the Appointment of Representative Form. If you wish to contact The Health Plan concerning an organization determination, please see the phone numbers and address below.

What is a Coverage Determination?

A coverage determination is a decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription is not covered under your plan, that is not a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are called "coverage decisions."

What is a Grievance?

A grievance is a type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. Another term for, "Making a Complaint" is "Filing a Grievance." The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive.

For more information on our grievance and appeals process, please see the section of the plan's evidence of coverage (EOC) document titled "What To Do If You Have A Problem Or Complaint (Coverage Decisions, Appeals, Complaints)." This section of the plan's EOC document explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon. The EOC document also explains how to make complaints about quality care, waiting times, customer service, and other concerns.

We encourage you to let us know right away if you have questions, concerns, or problems related to your covered services or the care you receive. If you would like information about the aggregate number of grievances, appeals, and exceptions filed with The Health Plan or have process or status questions, please call our Customer Service Department at 1.877.847.7907 (TTY users: 711). Hours of Operation are October 1 through March 31: 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30: 8:00 am to 8:00 pm, Monday through Friday. 

You can also mail or fax us at:
The Health Plan
1110 Main Street
Wheeling, WV 26003
FAX: 740.699.6163

You must contact us if you would like to request a coverage determination (including exception). You cannot request an appeal if we have not issued a coverage determination. Please call Member Services at 1.877.847.7907 (TTY users: 711). Hours of Operation are October 1 through March 31: 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30: 8:00 am to 8:00 pm, Monday through Friday. 

When asking for a Part D prescription drug benefit, the first step is called, "Requesting a Coverage Determination." When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests.

To access the Medicare Medication Request Form, click on the following link: Request for Medicare Prescription Drug Coverage Determination Form.

The following can be used to request an appeal on a denied medication request or direct claim denial, otherwise known as the Medicare Redetermination Request Form.

In order to authorize an individual to act as your representative for requesting a coverage determination or appeal, click on the following link: Appointment of Representative.

You can provide feedback directly to Medicare through their complaint form about your Medicare health or prescription drug plan.

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