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Grievances, Coverage Determinations and Appeals

Please call Customer Care or the NRECA Member Contact Center if you have questions, concerns, or problems related to your prescription drug coverage.

Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a participant in the Part D plan. The Medicare program has set some rules about what you need to do to make a complaint and what the Plan needs to do when someone makes a complaint. You cannot be disenrolled or penalized in any way if you make a complaint.

Grievance

A grievance is any complaint that expresses dissatisfaction with the Plan, such as how long you have to wait when you fill a prescription.

Coverage determinations, redeterminations and appeals are not grievances. For instance, any concerns you have about the Plan not covering or paying for a certain drug are handled through the coverage determination process, not as a grievance.

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

You are unable to reach someone by phone to get the information you need, or you experience other problems with the customer service you receive.
The network pharmacy is not clean.
You feel that you are being encouraged to leave (disenroll from) our Plan.
The pharmacist or other pharmacy staff are disrespectful or rude.
You disagree with our decision not to expedite your request for an expedited coverage determination or redetermination.
Notices and other written materials are difficult to understand.
You do not receive a decision within the required timeframe.
Your case is not forwarded to the independent review entity if the Plan does not give you a decision within the required timeframe.
The Plan does not provide required notices.

In certain cases, you have the right to ask for a “fast grievance,” meaning your grievance will be decided within 24 hours.

How to file a grievance

If you have a grievance, call Customer Care first.

The Plan will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, the Plan will respond in writing to you.

If your complaint cannot be resolved over the phone, there is a formal procedure to review your complaints.This is called the NRECA Grievance Process. You need to file your grievance within 60 calendar days from the date the incident occurred. The Plan will not accept any grievances filed more than 60 days from the date the incident occurred.

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

By phone: call a grievance team member at 866.884.9478
By fax: 866.788.5143
In writing: NRECA Medicare Part D Drug Plan, c/o Grievance Department, P.O. Box 280500, Nashville, TN 37228

Provide the following information when you submit your grievance:

Your name
Your ID number
The nature of the grievance
The date the grievance occurred
Your phone number
Your address if you are submitting the grievance in writing

The Plan needs your phone number (and address if in writing) to notify you of our decision.

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 a coverage determination, coverage redetermination, or an appeal.

How soon must the Plan decide on your grievance?

The Plan must notify you of our decision within 24 hours of receiving your complaint if

You filed a grievance about our denial of your request for a fast (expedited) decision on a coverage determination or redetermination, and
You have not yet purchased or received the drug in dispute.

For all other grievances, the Plan must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. The Plan may extend this timeframe up to 14 days if you request an extension, or if the Plan justifies a need for additional information and the delay is in your best interest.

For phone complaints, you will be notified by phone, unless your grievance is about a quality-of-care issue or you requested a written response, in which case we will inform you by letter.

For written grievances or grievances about quality-of-care issues, we will tell you of our decision by letter.

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

Complaints concerning the quality of care received under Medicare may be acted upon by the Medicare Part D prescription drug plan under the grievance process, an independent organization called the QIO, or both. For any complaint filed with the QIO, the Part D plan must cooperate with the QIO in resolving the complaint. Quality-of-care complaints filed with the QIO must be made in writing. You are not required to file the grievance within a specific time period. See the Introduction in your Summary Plan Description and Evidence of Coverage for more information about how to file a quality-of-care complaint with the QIO.

See the Summary Plan Description and Evidence of Coverage for your plan for more information.

Coverage Determinations

Coverage determinations include exception 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 exception) or believe you should get a drug at a lower coinsurance (tiering exception). If you request an exception, your doctor must provide a statement to support the medical necessity of your request.

How to request a coverage determination

You may request a coverage determination if you have problems getting the prescription drugs you believe the Plan should provide and you want to request a coverage determination.

We use the word “provide” in a general way to include such things as

authorizing prescription drugs
paying for prescription drugs
continuing to provide a Part D prescription drug that you have been getting

If your doctor or pharmacist tells you that the Plan will not cover a prescription drug, you should contact us and ask for a coverage determination. The following are examples of when you may want to ask us for a coverage determination:

You are not getting a prescription drug you believe may be covered by us.
You have received a Part D prescription drug you believe may be covered by us while you were a participant, but the Plan has refused to pay for the drug.
The Plan 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 may request a formulary exception.
You are not provided a drug because you and your prescribing doctor did not get prior authorization. You may request a formulary exception.
You disagree with the amount the Plan requires you to pay for a Part D prescription drug your doctor has prescribed for you. You may request an exception to the coinsurance the Plan requires you to pay for a drug.
You are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped.
There is a limit on the quantity (or dose) of the drug and you disagree with the requirement or dosage limitation.
There is a requirement that you try another drug before the Plan will pay for the drug you are requesting.
You bought a drug at a pharmacy that is not in our network and you want to request reimbursement for the expense.

Who may ask for a coverage determination?

You can request a coverage determination yourself, or your prescribing doctor or someone you name may do it for you.

The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

This statement must be sent to us at

NRECA’s Part D Plan
c/o SilverScript, LLC
Appeals Department, MC 109
P.O. Box 52000
Phoenix, AZ 85072-2000

You can call Customer Care to learn how to name your appointed representative.

You also have the right to have an attorney ask for a coverage determination on your behalf. You can 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.

Asking for a “Standard" or "Fast" Coverage Determination

A decision about whether the Plan will cover a Part D prescription drug can be a “standard" coverage determination that is made within the standard timeframe (typically within 72 hours), or it can be a “fast" coverage determination that is made more quickly (typically within 24 hours; see below). A fast decision is sometimes called an “expedited coverage determination.”

If your doctor requests or supports your request for a fast decision and shows that waiting for a standard decision could seriously harm your health or your ability to function, the Plan will automatically give you a fast decision.

If you ask for a fast coverage determination without support from a doctor, the Plan will decide if your health requires a fast decision. If the Plan decides that your medical condition does not meet fast coverage requirements, you will be sent a letter telling you that the Plan will supply a fast decision if you get a doctor’s support. The letter will also tell you how to file a grievance if you disagree with our decision. If the Plan denies your request for a fast review, it will give you its decision within the 72-hour standard time frame.

To ask for a standard or fast decision, you, your doctor, or your appointed representative should

call Customer Care Monday through Saturday from 6:30 a.m. to 11:00 p.m. C.T., or
fill out the Coverage Determination form or send a written request by fax to 866.884.9475 or
mail your form or written request to:

NRECA’s Part D Plan
c/o SilverScript, LLC
Appeals Department, MC 109
P.O. Box 52000
Phoenix, AZ 85072-2000

What happens when you request a coverage determination?

What happens, including how soon the Plan will decide, depends on the type of decision you request.

For a standard coverage determination, the Plan has to give you a decision within 72 hours of receiving your request, or sooner if your health condition requires.

However, if your request is for an exception — including a formulary exception, tiering exception, or an exception from utilization management rules, such as dosage, quantity limits, or step therapy requirement — the Plan must decide whether the exception is approved. Your doctor’s supporting statement needs to explain why the drug you are requesting is medically necessary.

If the Plan does not give you an answer within 72 hours of receiving your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

If you qualify for a fast coverage determination about a Part D drug you have not received, the Plan will give you a decision within 24 hours — sooner if your health requires.

If your request is for an exception, the Plan has to decide within 24 hours of receiving a supporting statement from your doctor. Your doctor must explain why the non-formulary or non-preferred drug you are requesting is medically necessary.

If the Plan decides you are eligible for a fast review and you have not received an answer from us within 24 hours after receiving your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

What happens if the Plan decides completely in your favor?

If the Plan makes a coverage determination that is completely in your favor, what happens next depends on the situation.

For a standard decision about a Part D drug, including a request about payment for a Part D drug that you already received:

The Plan must authorize or provide the benefit you have requested as quickly as your health requires, but no later than 72 hours after it received the request.

If your request involves a request for an exception, the Plan must authorize or provide the benefit no later than 72 hours after it gets your doctor's supporting statement. If you are requesting reimbursement for a drug that you already paid for and received, the Plan must send payment to you no later than 30 calendar days after it gets the request.

For a fast decision about a Part D drug that you have not received:

The Plan must authorize or provide you with the benefit you have requested no later than 24 hours after it received your request. If your request involves a request for an exception, the Plan must authorize or provide the benefit no later than 24 hours after it gets your doctor's supporting statement.

What happens if the Plan denies your request?

If your request is denied, the Plan will send you a written decision explaining the reason why your request was denied. The Plan may decide completely or only partly against you.

For example, if the Plan denies your request for payment for a Part D drug that you have already received, it may say that it will pay nothing or only part of the amount you requested. If a coverage determination does not give you all that you requested, you have the right to appeal the decision.

Appeals

An appeal is any procedure that deals with the review of an unfavorable coverage determination. You cannot request an appeal if the Plan has not issued a coverage determination.

If the Plan issues an unfavorable coverage determination, you may file an appeal called a redetermination if you want us to reconsider and change our decision. If our redetermination decision is unfavorable, you have additional appeal rights.

How to request an appeal

If you are unhappy with the coverage determination, you can ask for an appeal. The first level of appeal is called a redetermination. There are also four other levels of appeal you may request.

What kinds of decisions can be appealed?

You can appeal our decision not to cover a drug, vaccine, or other Part D benefit.
You can appeal our decision not to reimburse you for a Part D drug that you paid for.
You can appeal if you think you should have been reimbursed more than you received or if you are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription.
You can appeal if the Plan denies your exception request.
You can appeal a coverage determination if you disagree with our decision.

Please note: If the Plan approves your exception request for a non-formulary drug, you cannot request an exception to the coinsurance the Plan requires you to pay for the drug.

How does the appeals process work?

There are five levels to the appeals process as shown in this table:

Type of Appeal	Who reviews the appeal	Standard Process	Fast Process
Coverage Determination	Plan	· Decision within 72 hours	· Decision within 24 hours
Appeal Level 1	Plan	· Participant has 180 days to request appeal · Decision within 7 days	· Participant has 180 days to request appeal · Decision within 72 hours
Appeal Level 2	Independent review organization	· Participant has 60 days to request appeal · Decision within 7 days	· Participant has 60 days to request appeal · Decision within 72 hours
Appeal Level 3	Administrative Law Judge	· Participant has 60 days to request appeal · Minimum dollar amount for appeal to be reviewed · Decision made as soon as possible
Appeal Level 4	Medicare Appeals Council	· Participant has 60 days to request appeal · Minimum dollar amount for appeal to be reviewed · Decision made as soon as possible
Appeal Level 5	Federal District Court	· Participant has 60 days to request appeal · Minimum dollar amount for appeal to be reviewed · Decision made as soon as possible

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 other factors.

You make your request for coverage or payment of a Part D prescription drug directly to the Plan. The Plan reviews this request and makes a coverage determination. If our coverage determination is to deny any part of your request, you can go on to the first level of appeal by asking us to review our coverage determination.

If you are still dissatisfied with the outcome, you can ask for further review. If you ask for further review, your appeal is then sent outside of this 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 ensure a fair, impartial decision.

For more information on the Appeals process, refer to your Summary Plan Description and Evidence of Coverage, or call Customer Care.