COVERAGE INFORMATION

Coverage Determination (Exception), Appeal and Grievance Process

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 make a complaint if you have concerns or problems related to your coverage or care.

Appeals and grievances are the two different types of complaints you can make. The process varies slightly 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 or the Grievance and Appeal Coordinator can help you to assess how to proceed.

• Appeals
• Grievances
• Coverage Determination
• Other Resources

Appeals

An appeal is a type of complaint a member makes when they want Partnership to reconsider or change a decision we have already made.

Examples:

• 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 Part D Appeals
  PO Box 407
  Boys Town, NE 68010

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:

• 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 formal 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

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 a tiering or formulary exception. A request can also be made on your behalf by your appointed representative (See form below for Appointment of Representative) or your prescribing physician.

A request for a standard coverage determination is generally made in writing. A request for an Expedited Coverage Determination 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.

To request a coverage determination:

• 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:
  Part D Coverage Determinations
  PO Box 407
  Boys Town, NE 68010

A downloadable form for coverage determination is available below. 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.

Information for Providers

The Partnership Program must be contacted if you would like to request a coverage determination (including an exception). Please call 1-800-546-5677 24 hours a day, seven days a week (TTY Users should call 1-866-706-4757). You cannot request an appeal if we have not issued a coverage determination.

Important Information & Forms

The form documents below are Portable Document Format (PDF) files This format requires the free Adobe® Acrobat® Reader® software to open the file. It you do not have it installed on your computer, you can visit Adobe.com and download Adobe Acrobat Reader.

• Instructions for Member Request for Appeal or Grievance Form
• Member Request for Appeal or Grievance Form
• Instructions to Complete the Appointment of Representative Form
• Appointment of Representative Form
• Instructions to Complete the Member Request for Medicare Prescription Drug Coverage Determination Form
• Member Request for Medicare Prescription Drug Coverage Determination Form

Other Resources to Help You

You can also get free help and information from the Wisconsin Board on Aging and Long Term Care, your State Health Insurance Assistance Program, or SHIP: 1-800-242-1060. 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. Or, you can visit www.medicare.gov on the web.