2017 Medicare Select | Exceptions, Grievances and Appeals

For additional information on the grievance and appeals process please refer to The Evidence of Coverage for your plan. Click here for Medicare Select (HMO) Evidence of Coverage (EOC); click here for Medicare Select (HMO) Evidence of Coverage (EOC) in Spanish. Chapter 9 of the EOC provides detailed information which is also summarized below.

What is a coverage determination?

Whenever you ask 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.

What is a organization determination?

Organization Determination is the decision made by the Plan when you ask the Plan to provide, arrange or pay for services, in whole or in part, that you think should be covered by the plan.  

What is an exception?

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 list of covered drugs (formulary) or believe you should get a drug at a lower copay/coinsurance. If you request an exception, your physician must provide a statement to support your request.

You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

Complaints

You have the right to make a complaint if you have concerns related to your coverage or care. A complaint could be either a grievance or an appeal, or both. Every complaint must be handled under the appropriate grievance and/or appeal process.

What is an appeal?

(Part C)
Any of the procedures that deal wth the review of adverse organization determinations on the health care services an enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the enrollee), or on any amounts the enrollee must pay for a service.

(Part D)
An appeal is any of the procedures that deal with the review of an unfavorable coverage determination or organization determination, You must file a written appeal if you want us to reconsider and change the decision we have already made about what medical services or what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

What is a grievance?

(Part C)

Any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Medicare health plan, provider, or facility. An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame.  In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of health care.

(Part D)

Any complaint or dispute, other than a coverage determination or an LEP determination, expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. A grievance may also include a complaint that a Part D plan sponsor refused to expedite a coverage determination or redetermination. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item.

What types of problems might lead you to file a standard grievance?

A grievance is different from an appeal because usually it will not involve coverage or payment for medical or Part D prescription drug benefits (concerns about our failure to cover or pay for a certain drug should be addressed through the appeals process discussed above).

Here are some examples of issues that you might file a grievance:

  • If you feel that you are being encouraged to leave (disenroll from) a Medicare plan.
  • Problems with the customer care you receive.
  • Problems with how long you have to spend waiting on the phone or in the provider's office or pharmacy.
  • Disrespectful or rude behavior by providers or other staff.
  • Cleanliness or condition of a pharmacy or provider's office.
  • You believe our notices and other written materials are difficult to understand.
  • Failure to make a decision within the required time frame.
  • Failure to forward your case to the independent review entity if we do not make a decision within the required time frame.

When can you request a fast grievance?

You can request a fast grievance only if you disagree with our decision not to expedite your request for a fast (expedited) decision of an appeal, coverage determination, or coverage redetermination.

How soon must you file your grievance?

You need to file your grievance within 60 calendar days from the date the grievance occurred. We will not accept any grievances filed more than 60 days from the date the grievance occurred.

How do I submit a grievance?

You may submit a grievance over the phone, by fax, or by letter.

  1. Submit a grievance over the phone:

    Call the Grievance and Appeal Department at 303-602-2261. You may also receive assistance by calling Members Services at 303-602-2111 or toll free 1-877-956-2111. TTY users should call 711. Our hours of operation are 8 a.m. - 8 p.m. seven days a week.
  2. Submit a grievance via fax: 303-602-2078
  3. Submit a grievance in writing:

    Denver Health Medical Plan, Inc.
    Attn: Grievance and Appeal Department
    777 Bannock St, MC 6000
    Denver, CO 80204

What information do I need to provide when I submit my grievance?

We will need to know your name and your ID number. We will also need to know the nature of the grievance and the date the grievance occurred. Be sure to provide your phone number (and address if you are submitting the grievance in writing) so we can notify you of our decision.

How soon must we decide on your grievance?

How quickly we decide on your grievance depends on the type of grievance:

  1. For a standard grievance:

    After we receive your request for a grievance, we have up to 30 calendar days to make a decision.

  2. For a fast grievance:

    After we receive your request for a fast grievance, we have up to 24 hours to make a decision.

Can you request more time to research my grievance?

  1. For a standard grievance:

    Yes. We will notify you via a letter if we need additional time to research the grievance and we believe it is in your best interest to continue researching the grievance. We may ask for up to an additional 14 days.

  2. For a fast grievance:

    No. We must make a decision within 24 hours of receiving your request for a fast grievance.

How will you notify me of your decision?

We will use two methods of communication to notify you of our decision: telephone and letter.

  1. We will notify you by phone when:

    We will notify by phone if you submit a grievance verbally while on the phone with a Grievance and Appeal Department Representative. We will also follow up in writing of our decision.

  2. We will notify you by letter when:

    We will notify you by letter when you submit a grievance in writing (letter or fax).

What if I disagree with your decision on my grievance?

Per CMS regulations, all grievance decisions are final and not eligible for review or appeal.

What is an “organization determination”?

(Part C)
The “organization determination” made by Denver Health Medical Plan is the starting point for dealing with requests you may have about covering or paying for a medical service, medical treatment, or medical equipment . If your doctor tells you that a certain service or item is not covered, you may contact Denver Health Medical Plan and ask us for an initial organization determination. We will make a determination and explain whether we will provide the service or item you are requesting or have already  received.  If our decision is to deny your request (this is sometimes called an “adverse organization determination”), you can appeal the decision by going on to Appeal Level 1.

What is an “initial decision”?

(Part D)
The “initial decision” made by Denver Health Medical Plan is the starting point for dealing with requests you may have about covering or paying for a Part D prescription drug. If your doctor or pharmacist tells you that a certain prescription drug is not covered, you may contact Denver Health Medical Plan and ask us for an initial coverage decision. With this decision, we explain whether we will provide the prescription drug you are requesting or pay for a prescription drug you have already received. (This “initial decision” is sometimes called a “coverage determination.”) If our initial decision is to deny your request (this is sometimes called an “adverse coverage determination”), you can appeal the decision by going on to Appeal Level 1. If we fail to make a timely “initial decision” on your request, it will be automatically forwarded to an independent review entity for review.

Here are some examples of issues which you would request an organization determination/initial decision on:

  • You ask us to pay for a prescription drug you have already received; this is a request for an “initial decision” about payment. Click here for a claim form.
  • You ask for a Part D drug that is not on your plan's list of covered drugs (called a "formulary"), this is called a "formulary exception" request. Click here for a Request for Medicare Prescription Drug Coverage Determination form your provider will need to complete .
  • You ask for an exception to our plan’s utilization management techniques. These are also considered to be requests for “formulary exceptions.” Click here for a Prior Authorization form your provider will need to complete.
  • You ask for a non-preferred Part D drug at the preferred cost level, this is a request for a "tiering exception."
  • You ask that we reimburse you for a purchase you made from an out-of-network pharmacy. In certain circumstances, out-of-network purchases, including drugs provided to you in a physician’s office, will be covered by the plan.

When we make an organization determination/initial decision, we are giving our interpretation of how the Past C medical benefits and Part D prescription drug benefits that are covered for members of Medicare Choice and Medicare Select apply to your specific situation.

How do I request an initial decision?

You may request an initial decision over the phone, by fax, or by letter.

You can call the Grievance and Appeal Department at 303-602-2261. You may also receive assistance by calling Member Services at 303-602-2111 or toll free 1-877-956-2111. TTY users should call 711. Our hours of operation are 8 a.m. - 8 p.m. seven days a week.

Denver Health Medical Plan, Inc.
Attn: Grievance and Appeal Department
777 Bannock St, MC 6000
Denver, CO 80204

Enrollees: Click here for a Request for Medicare Prescription Drug Determination Request Form.
Providers: Click here for the Medicare Part D Coverage Determinations Request Form.
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Who may ask for an “initial decision” about a Part D benefit or payment?

You can ask us for an initial decision yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your appointed representative.

When can you request a fast decision?

You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function.

What happens when you request an “initial decision?”

What happens, including how soon we must decide, depends on the type of decision.

(Part C)

  1. When a member has made a request for a service, Denver Health Medical Plan must notify the member of its determination as expeditiously as the member's health condition requires, but no later than 14 calendar days after the date Denver Health Medical Plan receives the request for a standard organization determination.  Denver Health Medical Plan may extend the time frame up to 14 calendar days.  This extension is allowed to occur if the member requests the extension or if Denver Health Medical Plan justifies a need for additional information.  If the member disagrees with Denver Health Medical Plan's decision to grant an extension, the member may file a grievance.
  1. For a fast initial decision about a Part C medical service or item that you have not received.

A member, or any physician, may request that Denver Health Medical Plan expedite an organization determination when the member or his/her physician believes that waiting for a decision under the standard time frame could place the member's life, health, or ability to regain maximum function in serious jeopardy.

Denver Health Medical Plan must automatically provide a "fast" organization determination if a physician indicates, either orally or in writing, that applying the standard time for making a determination could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function.

For a request made by a member, Denver Health Medical Plan must expedite the review of a determination if the plan finds that applying the standard time for making a determination could seriously jeopardize the member's health, life, or ability to regain maximum function.  If Denver Health Medical Plan decides to expedite the request, it must render a decision as expeditiously as the member's health requires, but no later than 72 hours after receiving the member's request.

If Denver Health Medical Plan denies the request for a "fast" organization determination, the member may file a "fast" grievance.

Denver Health Medical Plan will tell the member in writing of our initial decision concerning the medical service or item the member has requested. The member will receive this notification when we make our decision, under the time frame explained above. If we do not approve the member's request, we must explain why, and tell you of the right to appeal our decision. The section "Appeal Level 1" explains how to file this appeal.  Please be advised that the appeal must be filed within sixty (60) calendar days of event occurrence or the receipt of an adverse notification by DHMP.

(Part D)

  1. For a standard initial decision about a Part D drug that has not been received yet, Denver Health Medical Plan must make our decision no later than 72 hours after we have received the member's request, but we will make it sooner if the member's health condition requires.  However, if the member's request involves a request for an exception we must make our decision no later than 72 hours after we have received a physician's "supporting statement," which explains why the drug the member is asking for is medically necessary.

When a member requests reimbursement for a Part D drug that the member has already received, Denver Health Medical Plan must make a decision and notify the member as quickly as the member's health condition requires, but no later than 14 calendar days after receiving the reimbursement request.

  1. For a fast initial decision about a Part D drug that has not been received yet:

If a member receives a “fast” review, Denver Health Medical Plan will give the member our decision within 24 hours after the member or a doctor asks for a “fast” review—sooner if the member's health requires. If the member's request involves a request for an exception, we must make our decision no later than 24 hours after we have received a physician's "supporting statement," which explains why the non-formulary or non-preferred drug the member is asking for is medically necessary.

Denver Health Medical Plan will tell the member in writing of our initial decision concerning the prescription drug the member has requested. The member will receive this notification when we make our decision, under the time frame explained above. If we do not approve the member's request, we must explain why, and tell the member of the right to appeal our decision. The section "Appeal Level 1" explains how to file this appeal.  Please be advised that the appeal must be filed within sixty (60) calendar days from the date on the denial notice from Denver Health Medical Plan.

What happens next if we decide completely in your favor?

If we make an “initial decision” that is completely in your favor, what happens next depends on the situation.

  1. For a standard decision about a Part D drug which includes a request about payment for a Part D drug that you already received. We must authorize or provide the benefit you have requested as quickly as your health requires, but no later than 72 hours after we received the request. If you are requesting reimbursement for a drug that you already paid for and received, we must send payment to you no later than 14 calendar days after we receive the request.
  2. For a fast decision about a Part D drug that you have not received. We must authorize or provide you with the benefit you have requested no later than 24 hours of receiving your request.

What happens next if we deny your request?

If we deny your request, we may decide completely or only partly against you. For example, if we deny your request for payment for a Part D drug that you have already received, we may say that we will pay nothing or only part of the amount you requested. If any initial decision does not give you all that you requested, you have the right to appeal the decision. (See Appeal Level 1)

What kinds of decisions can be appealed?

You can generally appeal our decision not to cover a drug, vaccine, or other Part D benefit. You may also appeal our decision not reimburse you for a Part D drug that you paid for. In addition, if you think we should have paid or reimbursed you more than you received, or the amount you are paying is more than you are supposed to pay under the plan, you can appeal. Finally, if we deny your exception request, you can appeal.

Here are some examples of situations where you might want to file an appeal:

  • If you are not getting a prescription drug that you believe may be covered by Medicare Choice or Medicare Select.
  • If you have received a Part D prescription drug you believe may be covered by Medicare Choice or Medicare Select while you were a member, but we have refused to pay for the drug.
  • If we will not provide or pay for a Part D prescription drug that your doctor has prescribed for you because it is not on our list of covered drugs (called a “formulary”). You can request an exception to our formulary.
  • If you disagree with the amount that we require you to pay for a Part D prescription drug that your doctor has prescribed for you. You can request an exception to the co-payment we require you to pay for a drug.
  • You have requested an exception to our formulary or to the co-payment for a drug and we have denied your request.
  • If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped.
  • If there is a requirement that you try another drug before we pay for the drug your doctor prescribed, or if there is a limit on the quantity (or dose) of the drug and you disagree with the requirement or dosage limitation.
  • You bought a drug at a pharmacy that is not in our network and you want to request reimbursement for the expense.
  • We do not make a decision on your request within the required time frame.

Please Note: If we approve your exception request for a non-formulary drug, you cannot request an exception to the co-payment we require you to pay for the drug.

How does the appeals process work?

There are five levels to the appeals process. Here are a few things to keep in mind as you read the description of these steps in the appeals process:

  • Moving from one level to the next. At each level, your request for Part D benefits or payment is considered and a decision is made. The decision may be partly or completely in your favor (giving you some or all of what you have asked for), or it may be completely denied (turned down). If you are unhappy with the decision, there may be another step you can take to get further review of your request. Whether you are able to take the next step may depend on the dollar value of the requested drug or on other factors.
  • “Initial decision” vs. “making an appeal.” Whenever you ask for a Part D benefit, the first step is called an “initial decision” or a “coverage determination.” If you are unhappy with the initial decision, you can ask for an appeal, which is called a redetermination. There are also four other levels of appeal that an enrollee may request.

Who makes the decision at each level?

You make your request for coverage or payment of a Part D prescription drug directly to us. We review this request and make an initial decision. If our initial decision is to turn down your request (in whole or in part) you can go on to the first level of appeal by asking us to review our initial decision. If you are still dissatisfied with the outcome, you can ask for further review. If you do, your appeal is then sent outside of Denver Health Medical Plan, where people who are not connected to us conduct the review and make the decision. After the first level of appeal, all subsequent levels of appeal will be decided by someone who is connected to the Medicare program or the federal court system. This will help insure a fair, impartial decision.

Appeal Level 1: If we deny part or all of your request in our initial decision, you may ask us to reconsider our decision. This is called an “appeal” or “request for redetermination.” You may ask us to reconsider our initial decision, even if only part of our decision is not what you requested. When we receive your request to reconsider the initial decision, we give the request to people at our organization who were not involved in making the initial decision. Click here for a Request for Redetermination of Medicare Prescription Drug Denial form.

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” initial decision.

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:

WRITE: Denver Health Medical Plan, Inc., Attn: Grievance and Appeal Department, 777 Bannock St, MC 6000 Denver, CO 80204

FAX: 303-602-2078

CALL: (if it is a “fast” appeal) 303-602-2261 or TTY at 711.

You also have the right to ask us for a copy of information regarding your appeal. You can call or write us at 303-602-2261 or TTY/TDD at 711, Denver Health Medical Plan, Inc., 777 Bannock St, MC 6000 Denver, CO 80204

How do you file your appeal of the initial decision?

The rules about who may file an appeal are almost the same as the rules about who may ask for an “initial decision."

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 initial decision. We can give you more time if you have a good reason for missing the deadline. Click here for Request for Reconsideration form.

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” initial decision.

How soon must we decide on your appeal?

How quickly we decide on your appeal depends on the type of appeal:

  1. 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 seven (7) calendar days to make a decision, but will make it sooner if your health condition requires us to. If we do not tell you our decision within seven (7) calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case.
  2. 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 make a decision, but will make it sooner if your health requires us to. If we do not tell you our decision within 72 hours, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

What happens next if we decide completely in your favor?

  1. 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 initial decision.
  2. 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.
  3. 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. For process or status questions call 303-602-2070. TTY/TDD users should call 303-602-2129 or toll free 1-866-538-5288.

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.

How to Obtain an Aggregate Number of the Plan's Grievances, Appeals and exceptions.

If you would like more information about Denver Health Medical Plan, Inc's. grievances, appeals and exceptions, please contact the Grievance and Appeal Department at 303-602-2261 or call Member Services at 303-602-2111 or toll free at 1-877-956-2111. TTY users should call 711. Our hours of operation are 8:00 a.m. to 8:00 p.m. seven days a week.

Appointing a Representative to Assist you with your Appeal or Coverage Determination Request

If you want to name someone to represent you and help you with your appeal or coverage determination request, please download and print the Appointment of Representative form. You and the individual you want to be your representative need to sign the form. If your representative is a lawyer, only you need to sign the form. The Appointment of Representative form does not need to be signed if your doctor calls on your behalf.

If you have any questions, would like to request an exception or an appeal or to check the status of an exception or an appeal, please call our Member Service Department toll free at 1-877-956-2111. TTY/TDD Hearing Impaired Access line users should call 711. Our hours of operation are 8 a.m. - 8 p.m. seven days a week.

H5608_4006_Denver Health Medical Plan, Inc.
CMS Approved
This page was last updated 01/10/2017