Medicare Appeals Process
Learn what an appeal is, how to file or fast track appeals and what to do if your appeal is denied.
What is an appeal?
An appeal, or redetermination, is a formal way to ask the plan to review a coverage decision about health care services and/or prescription drugs. You may ask for a review when you are not satisfied with our initial coverage decision. You may ask for an appeal if:
- You were denied payment for services and/or covered prescription drugs you already received or paid for.
- You do not agree with a decision to stop getting a particular service.
- HealthSpring doesn't pay for a drug, item or service you think you should be able to get.
You must make your request within 65 days from the date of the coverage determination.
Part C - Regulated Medical Appeals
Who can file?
You or your appointed representative (someone you name to act for you) may ask for a medical appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you with an Appointment of Representative form. Under state law, others may already be allowed to act for you. A physician who is giving you treatment may, upon giving you notice, ask for a standard reconsideration on your behalf without submitting a representative form.
Get an Appointment of Representative form
Types of Medical Appeals
- Standard Claim Appeals
If you are asking for reimbursement for medical care you have already received, this is a Standard Claim Appeal. We will give you an answer within 60 days of your filing. - Standard Medical Pre-Service Appeals
If you are asking for coverage for medical care you have not yet received, this is a Standard Medical Pre-Service Appeal. We will give you an answer within 30 days of your filing. We can take up to 14 more days if you ask for more time or if we need information that may help you. If we decide to take extra time, we will tell you in writing. Fast Medical (Expedited) Appeals
You or your doctor (without an Appointment of Representative form) can request a Fast Medical Appeal by phone or mail if waiting for a Standard Appeal could harm your health or your ability to function. You can get one:- For medical care you have not yet received
- If you're getting Medicare services from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility or hospice and you think your Medicare-covered services are ending too soon. Your doctor will give you a notice before your services end that will tell you how to ask for a Fast Medical Appeal in your area. An independent reviewer, called a Quality Improvement Organization (QIO), will decide if your services should continue.
We will give you an answer within 72 hours. We can take up to 14 more days if you ask for more time or if we need information that may help you. If we decide to take extra time, we will let you know.
How do I file my appeal?
For customers enrolled in a HealthSpring Medicare Advantage Plan with or without Prescription Drug Coverage
Mail
HealthSpring Medicare
Attn: Part C Regulated Medical Appeals
P.O. Box 188081
Chattanooga, TN 37422
Phone (Expedited Appeals Only):
Phone (Arizona Expedited Appeals Only):
Fax: 1-855-350-8671
Hours:
October 1 – March 31: 8 a.m. – 8 p.m., 7 days a week
April 1 – September 30: 8 a.m. – 8 p.m., Monday – Friday, 8 a.m. – 6 p.m., Saturday. Messaging service used weekends, after hours and federal holidays.
Part D - Pharmacy Appeals
Who can file a Pharmacy appeal?
You, your representative or your prescriber may request a pharmacy appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you with an Appointment of Representative form. Under state law, others may already be allowed to act for you.
Get an Appointment of Representative form
You must make your request within 65 days from the date of the coverage determination. A coverage determination is the first decision made by your Medicare drug plan (not the pharmacy) about your drug benefits.
Types of Pharmacy Appeals
- Standard Pharmacy Appeals
If you’re asking for a Standard Appeal for prescription drugs, we will give you an answer within 7 calendar days of receipt of your request. - Fast Pharmacy Appeals
You may also ask for a Fast Appeal for prescription drugs, if waiting for a Standard Appeal could seriously harm your health or your ability to function. If you are asking for a Fast Appeal for prescription drugs, we will give you an answer within 72 hours of receipt of your request.
How do I file my appeal?
For customers enrolled in a HealthSpring Medicare Advantage Prescription Drug Plan or a HealthSpring Medicare Standalone Part D Prescription Drug Plan:
Mail
Express Scripts
Attn: HealthSpring Medicare Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Phone:
Fax:
Hours:
October 1 – March 31: 8 a.m. – 8 p.m., 7 days a week
April 1 – September 30: 8 a.m. – 6 p.m., Monday – Friday, 8 a.m. – 6 p.m., Saturday. Messaging service used weekends, after hours and federal holidays.
If you are calling us to start a standard or Fast appeal after normal business hours, please include all of the following information in your message:
- Member's name
- Phone number
- Prescription being appealed with the strength
- Your doctor's name and phone number
- Clarification that you are requesting a Standard or Fast appeal
Denied Appeals
What if my appeal is denied?
If HealthSpring denies your appeal for medical care, we will send you an explanation of our decision in writing.
If our plan denies your appeal for a Part D prescription drug, you will need to choose whether to accept this decision or appeal it to Level 2. The notice we send you denying your Level 1 Appeal will include instructions on how to make a Level 2 Appeal.
Appeal Levels 3, 4 and 5
If you are dissatisfied with the Level 2 Appeal determination, you have the right to request a Level 3 appeal review if the amount in the appeal meets the required thresholds. The notice you get denying your Level 2 Appeal will tell you if the dollar value is high enough to move on to Level 3. If you qualify for a Level 3 Appeal, an Administrative Law Judge will review your appeal and make a decision. If you do not agree with the decision the judge makes, you can move on to a Level 4 Appeal.
At the Level 4 Appeal, the Medicare Appeals Council, who works for the federal government, will review your appeal and give you an answer. If you do not agree with the decision at Level 4, you may be able to move on to the next level of review.
A Level 5 Appeal is reviewed by a judge at the Federal District Court. This is the last stage of the appeals process. To learn more about these additional levels of appeal, see the Chapter named "What to do if You Have a Problem or Complaint" in your Evidence of Coverage.
Questions and Complaints
If you have questions about appeals, exceptions and/or grievances or if you want to get an aggregate total of appeals/exceptions/grievances filed with the plan, please call us at the numbers listed for your plan above.
If you have a complaint, you can send feedback straight to Medicare using the Medicare Complaint form