Exceptions, Grievances and Appeals
For additional information on the grievance and appeals process please refer to The Evidence of Coverage for your plan. (Click on link on the right of this page.) Chapter 9 of the EOC provides detailed information which is also summarized below.
Complaints!
You have the right to make a complaint if you have concerns or problems related to your coverage or care. “Appeals” and “Grievances” are the two different types of complaints you can make.
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 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.
What is an appeal?
An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.
What is a grievance?
A grievance is any complaint other than one that involves a coverage determination. It's the type of complaint you make if you have any other type of problem with your plan or one of our network providers or pharmacies. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your providers or others behave, being able to reach someone by phone or getting the information you need, or the cleanliness or condition of a network pharmacy.
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 Member Services: 303-602-2111. Our hours of operation are 8:00 a.m. - 8:00 p.m. seven days a week. TTY users should call 303-602-2129
2. Submit a grievance via fax: 303-602-2138
3. Submit a grievance in writing:
Address: Denver Health Medical Plan
c/o Grievance Team
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 Member Service Representative.
2. We will notify you by letter when:
We will notify you by letter when you submit a grievance in writing (letter or fax). We will notify by letter upon your request.
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 “initial decision”?
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 should 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 the independent review entity for review.
Here are some examples of issues which you would request an 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 a request for a "formulary exception." Click here for a Prior Authorization 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 “initial decision,” we are giving our interpretation of how the 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 Member Services at 303-602-2111. Our hours of operation are 8:00 a.m. - 8:00 p.m. seven days a week. TTY users should call 303-602-2129. Fax: 303-602-2138
Address: Denver Health Medical Plan
c/o Grievance Team
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.
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. Click here for Appointment of Representative form.
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. (Fast decisions apply only to requests for Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Part D drug that you already received.)
What happens when you request an “initial decision?”
What happens, including how soon we must decide, depends on the type of decision.
1. For a standard initial decision about a Part D drug which includes a request about payment for a Part D drug that you already received. We must make our decision no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. However, if your request involves a request for an exception we must make our decision no later than 72 hours after we have received your physician's "supporting statement," which explains why the drug you are asking for is medically necessary.
2. For a fast initial decision about a Part D drug that you have not received.
If you receive a “fast” review, we will give you our decision within 24 hours after you or your doctor ask for a “fast” review—sooner if your health requires. If your request involves a request for an exception, we must make our decision no later than 24 hours after we have received your physician's "supporting statement," which explains why the non-formulary or non-preferred drug you are asking for is medically necessary.
We will tell you in writing of our initial decision concerning the prescription drug you have requested. You will receive this notification when we make our decision, under the time frame explained above. If we do not approve your request, we must explain why, and tell you of your right to appeal our decision. The section "Appeal Level 1" explains how to file this appeal.
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 30 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.
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, 777 Bannock St, MC 6000 Denver, Co 80204
FAX 303-602-2138
CALL (if it is a “fast” appeal) 303-602-2070 or TTY at 303-602-2129
You also have the right to ask us for a copy of information regarding your appeal. You can call or write us at 303-602-2070 or TTY at 303-602-2129, Denver Health Medical Plan, 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 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 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 users should call 303-602-2129.
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 Member Services at 303-602-2111. TTY users should call 303-602-2129. 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 located below. 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.
Appointment of Representative Form click here.
Formulario para el Nombramiento de Representante haga clic aguí
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 Hearing Impaired Access line users should call 1-866-538-5288. We are open seven days a week from 8:00 a.m. to 8:00 p.m.