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MetroPlus Medicare Exceptions and Appeals Procedures
Coverage Determination
A coverage determination or coverage decision is a decision MetroPlus makes about your benefits and coverage or about the amount we will pay for your medical services or drugs. We make a coverage decision for you whenever you go to a doctor 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 before you receive it, you can ask us to make a coverage decision for you.
You can call MetroPlus Customer Services at 866-986-0356 or TTY 800-881-2812 from 8 am to 8 pm Monday to Saturday. Either you or your doctor can ask for a coverage decision, however, if you want a fast or expedited decision, you should consider getting your doctor involved.
You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal. There may be someone who is already legally authorized to act as your representative under State law. If you want a friend, relative, your doctor or other provider, or other person to be your representative, print out and complete the Appointment of Representative form. The form must be signed by you and by the person who you would like to act on your behalf. You must send in or fax (212-908-8701) MetroPlus a copy of the signed form.
You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision.
Exceptions
An exception is a type of coverage determination or coverage decision that, if approved, allows you to get a drug that is not on your plan sponsor's formulary (a formulary exception), or get a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).
You or your doctor can ask for an exception if your drug is not on our formulary or you want us to waive coverage restrictions or limits. To request an exception, please ask your provider to fill out the Medicare Part D Coverage Determination Request form. Please mail your request to informedRx, 9343 Tech Center Drive #200, Sacramento, CA 95826; or fax it to 516-403-2151. You or your doctor can also call 866-443-1095 (TTY 866-443-1094).
Appeals
An appeal is something you do if you disagree with a decision to deny a request for health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our Plan doesn't pay for a drug, item, or service you think you should be able to receive.
If you would like to ask us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what your share of the cost will be, you have the right to file an appeal. Please contact MetroPlus Customer Services at 866-986-0356 (TTY 800-881-2812) from 8 am to 8 pm Monday to Saturday for additional information.
If you would like to appoint another individual to act as your representative and file an appeal on your behalf, you will need to complete an Appointment of Representative form. The form must be signed by you and the person who you would like to act on your behalf. You must send in or fax (212-908-8701) a copy of the signed form.
Grievances
A grievance is a type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. As a member of the MetroPlus, you have the right to file a grievance if you have a complaint about our plan or one of our network pharmacies.
If you have a complaint, please contact MetroPlus Customer Services at 866-986-0356 (TTY 800-881-2812) from 8 am to 8 pm Monday to Saturday for additional information. We will try to resolve your complaint over the phone or within 24 hours of receipt of complaint. If you would like a written response to the complaint, we will send you a written response to your phone request. If we are unable to resolve your complaint over the phone, we have a formal complaint process called Member Complaints & Grievances Procedure. The Customer Services Representative will advise you that they are forwarding your complaint to our Complaints Unit for investigation and resolution. You also have the option of filing your complaint in writing by submitting your complaint to:
MetroPlus Health Plan
Medicare Complaints Unit
160 Water Street, 3rd Floor
New York, N.Y. 10038
HH0423_MKT1015_11/2009
11/19/2009
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