Coverage Determinations, Appeals, & Grievances
Most problems can be solved by your Partnership Team. If you have a problem, we encourage you to first call your Team at 715-838-2900 or 1-800-842-1814. We will try to resolve any problem that you might have over the phone. If the problem is not solved following your discussion with the Team, you have the right to file a grievance or appeal if you have concerns or problems related to your coverage or care.
As a Partnership program member, you have the right to grieve or appeal any action or inaction by CHP that you perceive as having a negative impact to your care. The process varies depending on whether it is a Medicare, Medicaid or a Part D Prescription Drug grievance or appeal. If you are not sure how to proceed, your Partnership Team, our Grievance and Appeal Coordinator, or our Member Rights Specialist can help you to assess how to proceed.
Coverage Determination
When the Partnership Program makes a coverage determination, we are making a decision whether or not to provide or pay for a Part D Prescription Drug, what your share of the cost is for the drug, as well as what services or benefits are covered for you and what we will pay for those services or benefits. Coverage determinations include exceptions requests. You have the right to ask us for an "exception" if you believe you need a drug that is not on our formulary or believe you should get a drug at a lower co-payment.
Under the Medicare Part D Prescription Drug benefit program, you as a member, can request a coverage determination, including a request for formulary exception. A request can also be made on your behalf by your appointed representative or your prescribing physician. (See Appointment of Representative form in the
Important Information and Forms section below)
A standard or expedited coverage determination request can be made orally or in writing. You, your appointed representative, or your prescribing physician may submit a written request for a coverage determination in any format.
There are two different types of coverage determinations:
- Prior Authorization
Certain drugs may require prior authorization (prior approval) for a variety of reasons. CHP's Pharmacy Benefit Manager (PBM) determines the prior authorization status of drugs on the basis of program requirements and ongoing evaluation of the drugs' utilization, therapeutic efficacy, safety, and cost.
- Formulary Exception
You can ask us to waive coverage restrictions or quantity limits on your drug.
Requesting a Coverage Determination
To request a Coverage Determination, you can download and complete a
Coverage Determination Form. The completed Coverage Determination Form can be faxed to: 1-866-632-7946. When completing this form, please be sure to:
- Check the type of coverage request you are seeking
- Indicate if you are seeking an "expedited exception"
- Include any supporting documentation from your prescribing physician
- Include signature and date signed
If you request an exception, your physician must provide a statement to support your request.
For more details about coverage determinations (decisions), please refer to the Evidence of Coverage: Chapter 8, Section 5 for Medicare decisions, and Section 12 for Medicaid decisions.
If you have any questions, you can contact our Pharmacy Benefit Manager at:
- Telephone: 1-800-546-5677 24 hours a day, seven days a week (TTY Users should call 1-866-706-4757)
- Facsimile: 1-866-632-7946
- Mail:
Medicare Appeals
PO Box 407
Boys Town, NE 68010
Redetermination
A member who has received a coverage determination for a Medicare Part D drug may request that it be redetermined. A member, a representative acting under the signed authority of a member (relative, advocacy group, state employee), and a member's prescribing physician (acting on behalf of the member) may request this redetermination. The redetermination process is used to review an adverse coverage determination.
A standard redetermination can be requested either orally or in writing by the member. An expedited redetermination can be requested either orally or in writing by the member or the member's prescribing physician. Requests for redeterminations can be directed to:
- TTY: 1-866-706-4757 This number requires special telephone equipment. Calls to this number are free.
- Facsimile: 1-866-632-7946
- Mail: Medicare Appeals PO Box 407 Boys Town, NE 68010
Requests for Coverage Determination or Redetermination can also be submitted on our secure website.
SUBMIT COVERAGE DETERMINATION OR
REDETERMINATION HERE.
Appeals
An appeal is a request made by you or someone on your behalf for review of an unfavorable decision. Examples of unfavorable decisions could include:
- Denial or limited authorization of a requested service
- Denial of a drug
- Reduction, suspension or termination of a previously authorized service
- Denial, in whole or part, of payment for a service
- Failure of Partnership to act within the timeframes provided
You or someone you name to act for you (your appointed representative) may request an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you.
If you wish to file an appeal, we encourage you to initially contact your team at 715-838-2900 or 1-800-842-1814. All appeals except Medicare Part D Prescription Drug appeals may be submitted orally or in writing via the following:
- Telephone – 715-838-2900 or 1-800-942-1814
- Facsimile – 715-838-2910
- Mail –
Community Health Partnership
Attn: Grievance and Appeal Coordinator
2240 EastRidge Center
Eau Claire, WI 54701
- In-person delivery
A downloadable form for Member Request for Appeal or Grievance Form is available below.
If you wish to file a Medicare Part D Prescription Drug Appeal or request a Coverage Determination, please do so via the following:
- Telephone: 1-800-546-5677
Calls to this number are free. This line is available 24 hours a day, seven days a week.
- TTY: 1-866-706-4757
This number requires special telephone equipment. Calls to this number are free.
- Facsimile: 1-866-632-7946
- Mail: Medicare Appeals
PO Box 407
Boys Town, NE 68010
For more details about appeals, please refer to the Evidence of Coverage: Chapter 8, Sections 6 and 7 for Medicare appeals, and Section 12 for Medicaid appeals.
Grievances
A grievance is a type of complaint that a member can make about Partnership or one of our plan providers. This type of complaint does not involve payment or coverage disputes.
Examples of grievances could include:
- Quality of services
- Office waiting times
- Behavior of service providers
- Adequacy of facilities
- Access to providers and/or services
- Refuse to expedite an organization determination or reconsideration
Partnership has a grievance and appeal committee whose primary purpose is to resolve any grievance or appeal at the plan level. A few of the pieces involved in this process are:
- Staff may be asked for information pertinent to a formal grievance or appeal
- Grievances and appeals are maintained in a confidential manner
- Members are free from discrimination or retaliation when they exercise their right to file a grievance or appeal
- Members or authorized representatives determine if they want to initiate the grievance and appeal process
For more details about grievances, please refer to the Evidence of Coverage: Chapter 8, Section 11.
Medicare Complaint Form
You can submit feedback about our Partnership Program directly to Medicare. The Centers for Medicare & Medicaid Services (CMS) values your feedback and will use your information to continue to improve the quality of the Medicare program. You can access the Medicare Complaint Form here.
Reconsideration
A member, who is dissatisfied with the redetermination, has the right to reconsideration by an independent review entity (IRE) who contracts with CMS. The member must file a written request for reconsideration with the IRE within 60 days of the date of the redetermination. Additional information about filing a reconsideration can be found in your Evidence of Coverage. If you disagree with the IRE decision, you will have additional appeal rights. You will be notified of these appeal rights if this happens.
How to Obtain Aggregate Numbers
To obtain the aggregate numbers of grievances, appeals and exceptions filed with Community Health Partnership, please contact Customer Service.
Important Information & Forms
Other Resources to Help You
- You can get free help and information from the Wisconsin Board on Aging and Long Term Care which offers an Ombudsman Program. You can contact this agency by telephone at 1-800-815-0015 or at their website: www.longtermcare.wi.gov.
- You can contact the State Health Insurance Assistance Program (SHIP) by telephone at 1-800-242-1060 or at their website: www.dhs.wisconsin.gov/aging/EBS/ship.htm.
- To ask questions or get free information booklets from Medicare, call 1-800-MEDICARE (1-800-633-4227). You can call this national Medicare helpline 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
- The Office of the Medicare Ombudsman can assist you with complaints, grievances, and information requests.
- For more information about Medicare, you can also visit their main website at: www.medicare.gov.
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