If you have a problem with your health care or prescription drug coverage, there are two main processes: Appeals for coverage decisions you disagree with, and Grievances for complaints about service, quality of care, or plan operations.
For more information, refer to Chapter 9 of your Evidence of Coverage for Imperial Senior Value 005 and Imperial Dynamic 012, or Chapter 7 of your Evidence of Coverage for Imperial Courage 016, or call Member Services at 1-800-838-8271, TTY: 711.
Organization Determinations
A coverage decision is a decision we make about your benefits and coverage, or about the amount we will pay for your medical services. For example, your plan network doctor makes a coverage decision for you whenever you receive medical care from him or her, or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a certain medical service, or if your healthcare provider refuses to provide medical care you think that you need. In other words, 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.
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 Medicare. If you disagree with any of our coverage decisions, you can make an appeal.
How to submit an Organization Determination (Coverage Decision):
- Phone: 1-800-838-8271, TTY: 711
- Fax: 1-626-380-9049
- Mail: Imperial Health Plan of California, Inc., Attn: Appeals & Grievances, PO Box 60874, Pasadena, CA 91116
Medical Coverage Appeals
You have the right to appeal if the plan or medical group denies, reduces, or denies payment (claim denial) for a medical service you believe you are entitled to receive.
The Appeals Process
- Level 1 — Plan Reconsideration
Submit your appeal within 65 days of the denial notice. For pre-service appeals (before you receive the service), the plan responds within 30 days for standard requests, or 72 hours for expedited (fast) requests. For post-service appeals (after you've already received the service), the plan responds within 60 days.
- Level 2 — Independent Review Entity (IRE)
If the plan upholds the denial, appeal to C2C Innovative Solutions, Inc. — an independent organization hired by Medicare, not the plan.
- Levels 3, 4, and 5
Further appeals are available through an Administrative Law Judge, the Medicare Appeals Council, and Federal District Court, depending on the dollar amount involved.
How to submit a level 1 appeal:
- Phone: 1-800-838-8271, TTY: 711
- Fax: 1-626-380-9049
- Mail: Imperial Health Plan of California, Inc., Attn: Appeals & Grievances, PO Box 60874, Pasadena, CA 91116
If requested by a representative, there are additional steps necessary before the request can be processed (please see the AOR section).
↑ Back to topPart D Drug Coverage Appeals
If you are denied coverage for a prescription drug, you have the right to request a redetermination (Level 1 Appeal). You have 65 days from the date of the denial notice to file. The plan will respond within 7 calendar days for standard coverage requests, 14 days for payment requests, or 72 hours for expedited (fast) requests.
If Level 1 is denied, you may continue to C2C Innovative Solutions, Inc. (IRE) for Level 2 review, and further levels after that.
How to submit a Part D appeal:
- Phone: 1-800-838-8271, TTY: 711
- Fax: 1-626-380-9049
- Mail: Imperial Health Plan of California, Inc., Attn: Appeals & Grievances, PO Box 60874, Pasadena, CA 91116
Grievances (Complaints)
A grievance is a complaint expressing dissatisfaction with the way Imperial Health Plan or our delegated entity provides health care services — anything other than a coverage decision, such as quality of care, wait times, provider behavior, or plan operations. You must file a grievance within 60 days from the date of the incident that precipitated the grievance.
Standard Grievances
The plan will respond within 30 calendar days of receiving your complaint.
Expedited (Fast) Grievances
You may request a fast grievance if the plan denied your request for a fast coverage decision or fast appeal, or if the plan requested additional time to resolve your complaint and you disagree. Fast grievances receive a response within 24 hours.
Part D Grievances
Complaints about a non-covered or excluded Part D drug may be filed as a standard grievance. The plan will respond within 30 calendar days.
Quality of Care Complaints — Quality Improvement Organization (QIO)
Important reminder: When your Grievance (complaint) is about quality of care, you also have additional options:
- You can make your complaint to the Quality Improvement Organization (QIO). If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our Plan). Livanta is California's QIO and can be reached through the following:
- Call: 1-877-588-1123 (TTY: 1-855-887-6668)
- Write to: Livanta BFCC-QIO Program, 9090 Junction Drive, Suite 10, Annapolis Junction, MD 20701
- Or if you wish, you can make your complaint about quality of care to our Plan and also to the Quality Improvement Organization, Livanta, following the same processes above.
How to file a grievance:
- Phone: 1-800-838-8271, TTY: 711
- Fax: 1-626-380-9049
- Mail: Imperial Health Plan of California, Inc., Attn: Appeals & Grievances, PO Box 60874, Pasadena, CA 91116
- Medicare directly: 1-800-MEDICARE (1-800-633-4227), TTY: 1-877-486-2048
You can also file a complaint about the plan by going directly to Medicare and calling 1-800-MEDICARE or going to Medicare.gov's complaint form. Additional information regarding the grievance process can be found on the Medicare website.
↑ Back to topAppointment of Representative
If you would like another person to act on your behalf in an appeal or grievance, they must be named as your representative using the form below. The completed AOR form must be received before the plan can process the request.
Submit by fax to 1-626-380-9049 or mail to Imperial Health Plan of California, Inc., Attn: Appeals & Grievances, PO Box 60874, Pasadena, CA 91116.
↑ Back to topAdditional Medicare Resources
Open a topic below to learn more about Part D coverage determinations, exceptions, and redeterminations. Source links in each topic, and the Medicare links at the bottom of this section, go to external websites outside of imperialhealthplan.com. Imperial Health Plan is not responsible for the content or privacy practices of external sites.
Coverage Determinations
Introduction
A coverage determination is any decision made by the Part D plan sponsor regarding:
- Receipt of, or payment for, a prescription drug that an enrollee believes may be covered;
- A tiering or formulary exception request (for more information about exceptions, see Exceptions below);
- The amount that the plan sponsor requires an enrollee to pay for a Part D prescription drug and the enrollee disagrees with the plan sponsor;
- A limit on the quantity (or dose) of a requested drug and the enrollee disagrees with the requirement or dosage limitation;
- A requirement that an enrollee try another drug before the plan sponsor will pay for the requested drug and the enrollee disagrees with the requirement; or
- A decision whether an enrollee has, or has not, satisfied a prior authorization or other utilization management requirement.
How to Request a Coverage Determination
An enrollee, an enrollee's prescriber, or an enrollee's representative may request a standard or expedited coverage determination by filing a request with the plan sponsor. Standard or expedited requests for benefits may be made verbally or in writing. Standard requests for payment must be made in writing, unless the plan sponsor accepts requests verbally. Written requests may be made by using the Request for Medicare Prescription Drug Coverage form, available in English and Spanish.
How a Plan Sponsor Processes Coverage Determination Requests
For requests for benefits that do not involve exceptions, a plan sponsor must provide notice of its decision within 24 hours after receiving an expedited request or 72 hours after receiving a standard request. The initial notice may be provided verbally so long as a written follow-up notice is mailed to the enrollee within 3 calendar days of the verbal notification.
For requests for benefits that involve exceptions, the adjudication timeframes do not begin until the plan sponsor receives the supporting statement from the enrollee’s prescriber.
For payment requests, including payment requests that involve exceptions, a plan sponsor must provide written notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request.
If the plan sponsor's coverage determination is unfavorable, the decision will contain the information needed to file a request for redetermination with the plan sponsor.
Source: CMS: Coverage Determinations
Exceptions
Introduction
An exception request is a type of coverage determination. An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception.
- A tiering exception should be requested to obtain a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier.
- A formulary exception should be requested to obtain a Part D drug that is not included on a plan sponsor's formulary, or to request to have a utilization management requirement waived (e.g., step therapy, prior authorization, quantity limit) for a formulary drug.
Exceptions requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee. Therefore, an enrollee's prescriber must submit a supporting statement to the plan sponsor supporting the request.
- For tiering exceptions, the prescriber's supporting statement must indicate that the preferred drug(s) would not be as effective as the requested drug for treating the enrollee's condition, the preferred drug(s) would have adverse effects for the enrollee, or both.
- For formulary exceptions, the prescriber's supporting statement must indicate that the non-formulary drug is necessary for treating an enrollee's condition because all covered Part D drugs on any tier would not be as effective or would have adverse effects, the number of doses under a dose restriction has been or is likely to be less effective, or the alternative(s) listed on the formulary or required to be used in accordance with step therapy has(have) been or is(are) likely to be less effective or have adverse effects.
How to Submit a Supporting Statement
A prescriber may submit his or her supporting statement to the plan sponsor verbally or in writing. If submitted verbally, the plan sponsor may require the prescriber to follow-up in writing.
A prescriber may submit a written request by using the Request for Medicare Prescription Drug Coverage form, available in English and Spanish.
How a Plan Sponsor Processes an Exception Request
For requests for benefits, once a plan sponsor receives a prescriber's supporting statement, it must provide written notice of its decision within 24 hours for expedited requests or 72 hours for standard requests. The initial notice may be provided verbally so long as a written follow-up notice is mailed to the enrollee within 3 calendar days of the verbal notification.
For requests for payment that involve exceptions, a plan sponsor must provide notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request.
If the plan sponsor's coverage determination is unfavorable, the decision will contain the information needed to file a request for redetermination with the plan sponsor.
Source: CMS: Exceptions
Redetermination by the Part D Plan Sponsor
Introduction
If a Part D plan sponsor denies an enrollee’s request, in whole or in part, the enrollee, the enrollee's prescriber, or the enrollee's representative may appeal the decision to the plan sponsor by requesting a standard or expedited redetermination.
How to Request a Redetermination
Redetermination requests must be filed with the plan sponsor within 65 calendar days from the date of the notice of the coverage determination. Expedited requests may be made verbally or in writing. Standard requests must be made in writing, unless the enrollee's plan sponsor accepts verbal requests (an enrollee should call the plan or check his or her Evidence of Coverage to determine if the plan accepts verbal requests).
Written requests may be made by using the Request for Redetermination of Medicare Prescription Drug Denial form, available in English and Spanish.
How a Plan Sponsor Processes Redetermination Requests
Once the request is received by the plan sponsor, it must make its decision and provide written notice of its decision as quickly as the enrollee's health requires, but no later than 72 hours (for expedited requests) or 7 calendar days (for standard requests) from receipt of the request. For payments, plan sponsors must provide written notice of their decision (and make payment, when appropriate) within 14 calendar days after receiving a request. For expedited redeterminations, initial notice may be provided verbally so long as a written follow-up notice is mailed to the enrollee within 3 calendar days of the verbal notification.
If the decision is unfavorable, the decision will contain the information an enrollee needs to file a request for a reconsideration by the Independent Review Entity (IRE). If the decision relating to an at-risk determination under a drug management program is unfavorable to the enrollee, in whole or in part, the plan sponsor must submit the case file and its decision for automatic review by the Part D IRE.
Source: CMS: Redeterminations
You can also contact Medicare at 1-800-MEDICARE (1-800-633-4227), TTY: 1-877-486-2048, available 24/7.
↑ Back to topPO Box 60874, Pasadena, CA 91116
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Imperial Health Plan is an (HMO) (HMO SNP) with a Medicare Contract. Enrollment in Imperial Health Plan depends on contract renewal.
Imperial Health Plan of California (HMO) (HMO SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Imperial does not exclude anyone or treat them unfairly because of race, color, national origin, age, disability, or sex. ATTENTION: If you speak English, free language assistance services are available to you. Appropriate auxiliary aids and services to provide information in accessible formats are also available free of charge. Call 1-800-838-8271 (TTY: 711) or speak to your provider.