Medicare Coverage Decisions, Appeals and Grievances

Important Contacts

You may contact Health Plan Services for help with coverage decisions, general questions or filing a grievance or appeal.

Health Plan Services

• Call:
  303-602-2261, TTY 711
  8 a.m. to 8 p.m., seven days a week.
• Fax:
  303-602-2078
• Write:
  Denver Health Medical Plan, Inc.
  Attn: Grievances and Appeals Department
  777 Bannock St., MC6000
  Denver, CO 80204

Documents

For additional information regarding coverage decisions, appeals, and complaints, please refer to the Evidence of Coverage (EOC) for your plan. 

Evidence of Coverage (EOC)

• Medicare Choice (HMO D-SNP) Evidence of Coverage (EOC)
• Medicare Select (HMO) Evidence of Coverage (EOC)

Forms

• Medicare Appointment of Representative Form
• Medicare Grievance and Appeal Form 
• Medicare Prescription Drug Determination Request Form
• Request for Redetermination of Medicare Prescription Drug Denial Form
• MedImpact Claim Form

Coverage Decisions

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 and/or your provider make a coverage decision for you whenever you go to a provider for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service or a prescription drug before you receive it, you can ask us to make a coverage decision.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by DHMP. If you disagree with this coverage decision, you can file an appeal.

How do I ask for a coverage decision about my medical (Part C) benefits?

Step 1:
You, your provider, or someone acting on your behalf (your appointed representative) may ask us to make a coverage decision on medical care for you. If your health requires a quick response, you should ask us to make a "fast decision."

To request a coverage decision:

• Call:
  Health Plan Services at 303-602-2111 or toll-free 1-877-956-2111, TTY 711.
  Our hours of operation are 8 a.m. to 8 p.m., seven days a week.
• Fax:
  303-602-2128
• Write:
  Denver Health Medical Plan, Inc.
  Attn: Utilization Management
  777 Bannock St., MC6000
  Denver, CO 80204

Step 2:
Our plan considers your request for medical care coverage and we give you our answer.

• For a “fast decision,” we will give you our answer within 72 hours.
• We will respond to standard coverage requests for services or benefits within 14 days of receiving your request.
• We will respond to requests for payment within 30 days of receiving your request.

Step 3:
If we say no to your request for coverage for medical care, you may submit an appeal. To submit an appeal, see the “APPEALS” section below.

How do I ask for a coverage decision about my prescription drug (Part D) benefits?

Step 1:
You, your provider or someone acting on your behalf (your appointed representative) may ask us to make a coverage determination for you. If your health requires a quick response, you should ask us to make a "fast decision."

Complete the appropriate form below and submit it by fax or mail. If you would like the form mailed to you, please call Health Plan 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. to 8 p.m., seven days a week.

• Medicare Prescription Drug Determination Request Form
• MedImpact Claim Form (if you are asking to us to pay for a prescription drug that you have already received)

If you are asking for us to cover a drug that is not on our drug list (“formulary”), please also include both of the following:

• A statement that none of the drugs used to treat your condition in our plan’s formulary would be as effective and/or all of the formulary drugs have caused you adverse effects
• A list of all of the drugs you have previously tried

To submit your request:

• Call:
  Health Plan Services at 303-602-2111 or toll-free 1-877-956-2111, TTY 711.
  Our hours of operation are 8 a.m. to 8 p.m., seven days a week.
• Fax:
  303-602-2081
• Write:
  Denver Health Medical Plan, Inc.
  Attn: Pharmacy Department
  777 Bannock St., MC6000
  Denver, CO 80204

Step 2:
Our plan considers your request for drug coverage and we give you our answer.

• For a “fast decision,” we will give you our answer within 24 hours.
• We will respond to standard coverage requests for prescription drugs within 72 hours of receiving your request.
• We will respond to coverage requests for payment of a drug you previously paid out of pocket for within 14 days of receiving your request.

Step 3:
If we say no to your request for drug coverage, you may submit an appeal. To submit an appeal, see the “APPEALS” section below.

Appeals

What is an appeal?

An appeal is a type of complaint you make when you disagree with our decision to deny your request for health care services or payment for services you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if we do not pay for an item or service you think you should be able to get. There is a specific process DHMP must use when you ask for an appeal.

How do I submit an appeal?

You or someone acting on your behalf (your appointed representative) may submit an appeal. If your health requires a quick response, you should ask us to make a "fast decision."

Complete the appropriate form below and submit it by either fax or mail. If you would like the form sent to you, please call Health Plan 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. to 8 p.m., seven days a week.

• For appeals related to your medical (Part C) coverage: Grievance and Appeal Form.
• For appeals related to your prescription drug (Part D) coverage: Request for Redetermination of Medicare Prescription Drug Denial Form.

To submit your appeal:

• Call:
  Grievances and Appeals at 303-602-2261.
  Our hours of operation are 8 a.m. to 8 p.m., seven days a week.
• Fax:
  303-602-2078
• Write:
  Denver Health Medical Plan, Inc.
  Attn: Grievances and Appeals Department
  777 Bannock St., MC6000
  Denver, CO 80204

You need to file your appeal within 60 calendar days from the date included on the notice of our initial coverage decision. We can give you more time if you have a good reason for missing the deadline.

How soon must we decide on your appeal?

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

For appeals related to your medical (Part C) benefits:

• For a “fast decision” on a service or benefit, we will give you our answer within 72 hours.
• We will respond to a standard appeal for services or benefits within 30 days of receiving your appeal.
• We will respond to an appeal for payment within 60 days of receiving your appeal.

For appeals related to your prescription drug (Part D) benefits:

• For a “fast decision” on a service or benefit, we will give you our answer within 72 hours.
• We will respond to a standard appeal for prescription drugs within 7 days of receiving your appeal.
• We will respond to an appeal for payment within 14 days of receiving your appeal.

How do I get information for or about my appeal?

We must gather all the information we need to make a decision about your appeal. If we need your help in getting 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.

To give us your additional information or ask for a copy of the information regarding your appeal:

• Call:
  Grievances and Appeals at 303-602-2261.
  Our hours of operation are 8 a.m. to 8 p.m., seven days a week.
• Fax:
  303-602-2078
• Write:
  Denver Health Medical Plan, Inc.
  Attn: Grievances and Appeals Department
  777 Bannock St., MC6000
  Denver, CO 80204

What happens if my request is still denied?

If your request is still denied in whole or in part after our appeal review, Medicare will provide you with a new and impartial review of your case by an independent reviewer outside of our organization. If you disagree with the decision of the independent reviewer, you will have further appeal rights. You will be notified of those appeal rights if this happens.

Grievances

What is a grievance?

A grievance is a complaint about the operation, activities, or behavior of our plan. This could include problems related to quality of care you receive, wait times, or our plan’s benefits. A grievance is not the way you deal with a complaint about a coverage decision. For those situations, see the “APPEALS” section above.

How do I submit a grievance?

You or someone acting on your behalf (your appointed representative) may submit a grievance by fax, mail or calling Health Plan Services.

Complete the form below and submit it by either fax or mail. If you would like the form sent to you, please call Health Plan 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. to 8 p.m., seven days a week.

• Medicare Grievance and Appeal Form

To submit your grievance:

• Call:
  Grievances and Appeals at 303-602-2261.
  our hours of operation are 8 a.m. to 8 p.m., seven days a week.
• Fax:
  303-602-2078
• Write:
  Denver Health Medical Plan, Inc.
  Attn: Grievances and Appeals Department
  777 Bannock St., MC6000
  Denver, CO 80204

You need to file your grievance within 60 calendar days from the date of the event the grievance occurred.

How soon must we decide on your grievance?

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

• For a “fast grievance,” we will give you our answer within 24 hours.
• We will respond to a standard grievance within 30 days of receiving your grievance.

Appointing a Representative

What is an appointed representative?

An authorized representative is the person you choose to help with or handle affairs related to your health care services. This can be a Power of Attorney, a family member, friend, caregiver, or an advocate. Your authorized representative can help you with a coverage decision, appeal or grievance.

How do I appoint a representative?

You may appoint someone else to act as your representative by filling out the Appointment of Representative Form. Both you and your representative must sign the form.

When complete, mail the form to:

Denver Health Medical Plan, Inc.
Attn: Health Plan Services
777 Bannock St., MC6000
Denver, CO 80204

More Information

What if I still have questions?

For more information, contact the DHMP Health Plan Services Department or Grievances and Appeals.

Medicare Health Plan Services
303-602-2111, toll-free 1-877-956-2111, TTY 711
Fax: 303-602-2138
8 a.m. to 8 p.m., seven days a week

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 or Appeals and Exceptions, please contact the Grievances and Appeals Department or Health Plan Services at the phone numbers listed above.

How to file a complaint directly with the Centers for Medicare & Medicaid Services (CMS)

You are able to submit feedback or complaints about your Medicare health plan or prescription drug plan directly to the CMS 24-hour helpline by calling 1-800-MEDICARE or by submitting a complaint using the Medicare Complaint form on the Medicare website. For more information, visit www.medicare.gov.