What is an appeal?
An appeal is any of the procedures that deal with the review of an unfavorable coverage
determination. You would file an appeal if you want us to reconsider and change
a decision we have made about what Part D prescription drug benefits are covered
for you or what we will pay for a prescription drug.
If we deny part or all or part of your request in our coverage determination,
you may ask us to reconsider our decision. This is called an “appeal” or “request
for redetermination.”
Please call us at (866) 314 2427 or TTY (888) 205 7671 if you need help with filing
your appeal. You may ask us to reconsider our coverage determination, even if only
part of our decision is not what you requested. When we receive your request to
reconsider the coverage determination, we give the request to people at our organization
who were not involved in making the coverage determination. This helps ensure that
we will give your request a fresh look.
How you make your appeal depends on whether you are requesting reimbursement for
a Part D drug you already received and paid for, or authorization of a Part D benefit
(that is, a Part D drug that you have not yet received). If your appeal concerns
a decision we made about authorizing a Part D benefit that you have not received
yet, then you and/or your doctor will first need to decide whether you need a fast
appeal. The procedures for deciding on a standard or a fast appeal are the same
as those described for a standard or fast coverage determination.
Getting information to support your appeal
We must gather all the information we need to make a decision about your appeal.
If we need your assistance in gathering this information, we will contact you. You
have the right to obtain and include additional information as part of your appeal.
For example, you may already have documents related to your request, or you may
want to get your doctor’s records or opinion to help support your request. You may
need to give the doctor a written request to get information.
You can give us your additional information in any of the following ways:
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In writing, to Central Health Plan, Member Services Department, 1540 Bridgegate Drive, Diamond Bar, CA 91765.
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By fax, at (626) 388-2361.
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By telephone – if it is a fast appeal – at (866) 314 2427 or TTY (888) 205 7671
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In person, at Member Services Department, 1540 Bridgegate Drive, Diamond Bar, CA 91765.
You also have the right to ask us for a copy of information regarding your appeal.
You can call us at (866) 314 2427 or TTY (888) 205 7671, or write us at Central
Health Medicare Plan, Member Services Department, 1540 Bridgegate Drive, Diamond Bar, CA 91765.
How soon must you file your appeal?
You need to file your appeal within 60 calendar days from the date included on the
notice of our coverage determination. We can give you more time if you have a good
reason for missing the deadline.
To file a standard appeal, you can send the appeal to us in writing at Central Health
Medicare Plan, Member Services Department, 1540 Bridgegate Drive, Diamond Bar, CA 91765
or by fax to (626) 388 2361.
To file a standard appeal, you can also call us at (866) 314 2427 or TTY (888) 205
7671.
What if you want a fast appeal?
The rules about asking for a fast appeal are the same as the rules about asking
for a fast coverage determination. You, your doctor, or your appointed representative
can ask us to give a fast appeal (rather than a standard appeal) by calling us at
(866) 314 2427 or TTY (888) 205 7671. Or, you can deliver a written request to Central
Health Medicare Plan, Member Services Department, 1540 Bridgegate Drive, Diamond Bar, CA 91765,
or fax it to (626) 388 2361. For after business hours request
please call (866) 314 2427. Be sure to ask for a “fast,” "expedited," or “72-hour”
review. Remember, that if your prescribing physician provides a written or oral
supporting statement explaining that you need the fast appeal, we will automatically
treat you as eligible for a fast appeal.
How soon must we decide on your appeal?
How quickly we decide on your appeal depends on the type of appeal:
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For a standard decision about
a Part D drug, which includes a
request for reimbursement for a Part D drug you already paid for and received.
After we receive your appeal, we have up to 7 calendar days to give you a decision,
but will make it sooner if your health condition requires us to. If we do not give
you our decision within 7 calendar days, your request will automatically go to the
second level of appeal, where an independent organization will review your case.
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For a fast decision about a
Part D drug that you have not received.
After we receive your appeal, we have up to 72 hours to give you a decision, but
will make it sooner if your health requires us to. If we do not give you our decision
within 72 hours, an independent organization will review your case.
What happens next if we decide completely in your favor?
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For a decision about reimbursement for a Part D drug you already paid for and
received.
We must send payment to you no later than 30 calendar days after we receive your
request to reconsider our coverage determination.
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For a standard decision about a Part D drug you have not received.
We must authorize or provide you with the Part D drug you have asked for as quickly
as your health requires, but no later than 7 calendar days after we received your
appeal.
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For a fast decision about a Part D drug you have not received.
We must authorize or provide you with the Part D drug you have asked for within
72 hours of receiving your appeal – or sooner, if your health would be affected
by waiting this long.
What happens next if we deny your appeal?
If we deny any part of your appeal, you or your appointed representative have the
right to ask an independent organization, to review your case. This independent
review organization contracts with the federal government and is not part of Central
Health Medicare Plan. Refer to your Evidence Of Coverage
booklet or contact Medicare as follows:
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Call 1-800-MEDICARE (1-800-633-4227) to ask questions or get free information booklets
from Medicare. You can call this national Medicare helpline 24 hours a day, 7 days
a week. TTY users should call 1-877-486-2048. Calls to these numbers are free.
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Use a computer to look at
www.medicare.gov, the official government website for Medicare information.
This website gives you a lot of up-to-date information about Medicare and nursing
homes and other current Medicare issues. It includes booklets you can print directly
from your computer. It has tools to help you compare Medicare Advantage Plan and
Prescription Drug Plans in your area. You can also search the “Helpful Contacts”
section for the Medicare contacts in your state. If you do not have a computer,
your local library or senior center may be able to help you visit this website using
their computer.