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Part D Appeals & Grievances (Redetermination)

An appeal or "redetermination" is any of the procedures that deal with the review of an unfavorable coverage determination. You should 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.

You can also Contact Us to get the aggregate numbers of grievances, appeals and exceptions filed with us; to question processes; or to ask about the status of a previously submitted grievance, appeal or exception. 

From October 2021-December 31, 2021:

For an Expedited Appeal: We suggest contacting us by telephone at 410-779-9932 or toll-free at 1-844-386-6762 (TTY users: 711) 8 AM to 8 PM, Monday through Friday (voice mail is available after business hours and provides instructions on the information needed and when resolution will be provided.  Or, submit your request to us by fax at 1-844-329-0831. Be sure to ask for a "fast or expedited review." This means you are asking us to give you an answer using the expedited deadlines rather than the standard deadlines. You can request an expedited (fast) appeal for cases that involve prescription drug coverage determinations if you or your doctor believes that your health could be seriously harmed by waiting up to 7 days for a decision. If your request to expedite is granted, we must make a decision no later than 72 hours after receiving your appeal. 

For a Standard Appeal: Make your standard appeal in writing by submitting a request.  Standard appeals must be in writing. Please send your appeal to us at the address or fax below. You can request a standard appeal for a case that involves prescription drug coverage or payment determinations. We must give you a decision no later than 7 days after receiving your appeal with up to 30 days to process payment for claim appeals.

You may write to us or use the below forms to Request Appeal Redetermination of Medicare Prescription Drug Denial:

CareFirst BlueCross BlueShield Medicare Advantage
Attention:  Appeals & Grievance Department
PO Box 915
Owings Mills, MD 21117

For your convenience, you can also use our online form to electronically request your appeal.  Please see the Pharmacy Forms section of this website.

For more information about your appeal rights, call Member Services at the number located on the back of your ID card, refer to the Evidence of Coverage, or visit the Contact Us page of this website. 

Effective January 1, 2022, the contact information for Part D Appeals and Grievances will change as follows.

To start your appeal, a member, prescriber, or a member's appointed representative must contact us within 60 calendar days of the date of the denial notice they received (unless the filing window is extended). You, your prescriber, or your appointed representative may ask for an expedited (fast) or standard appeal via any of the following ways:

Phone:

Contact customer service for any requests including making an oral request to Coverage Determination and Appeals. Our customer service team is available 24/7/365 at 1-844-786-6762 (TTY: 711). Appeals calls are then redirected to the correct department for further action. Other means of contact are provided below.

Fax: 1-855-633-7673

Online: Request for a Redetermination of a Denial of Prescription Drug Coverage

Mail:
CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000
Phoenix, AZ 85072-2000

You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at: www.Medicare.gov/MedicareComplaintForm/home.aspx

For an Expedited Appeal: Be sure to ask for a "fast or expedited review." This means you are asking us to give you an answer using the expedited deadlines rather than the standard deadlines. You can request an expedited (fast) appeal for cases that involve prescription drug coverage determinations if you or your doctor believes that your health could be seriously harmed by waiting up to 7 days for a decision. If your request to expedite is granted, we must make a decision no later than 72 hours after receiving your appeal.

For your convenience, you can also use our online form to electronically request your appeal.  Please see the Pharmacy Forms section of this website.

For more information about your appeal rights, refer to the Evidence of Coverage, or visit the Contact Us page of this website. 

GRIEVANCES

The grievance process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the grievance process.

Grievance

Example

Respecting your privacy

  • Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?

Disrespect, poor customer service, or other negative behaviors

  • Has someone been rude or disrespectful to you?
  • Are you unhappy with how our Member or Customer Service has treated you?
  • Do you feel you are being encouraged to leave the plan?

Information you get from us

  • Do you believe we have not given you a notice that we are required to give?
  • Do you think written information we have given you is hard to understand?

Timeliness
(These types of grievances are all related to the timeliness of our actions related to coverage decisions and appeals)

If you are asking for a decision or making an appeal, you use that process, not the grievance process. However, if you have already asked us for a coverage decision or made an appeal, and you think that we are not responding quickly enough, you can also make a grievance about our slowness. Here are examples:

  • If you have asked us to give you a “fast coverage decision” or a “fast appeal, and we have said we will not, you can make a grievance.
  • If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a grievance.
  • When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a grievance.

 

To file a grievance between October 2021-December 31, 2021 you can do the following: 

  • Usually, calling Member Services is the first step.  You can call Member Services at 410-779-9932 or toll-free at 1-844-386-6762 (TTY users: 711) 8 AM to 8 PM, 7 days a week from October 1 through March 31 and 8 AM to 8 PM, Monday through Friday from April 1 through September 30 to file a verbal grievance.
  • If you do not wish to call (or you called and were not satisfied), you can put your grievance in writing and send it to us. If you put your grievance in writing, we will respond to your grievance in writing.  Submit your written grievance to us at:

    CareFirst BlueCross BlueShield Medicare Advantage
    Attention:  Appeals & Grievance Department
    PO Box 915
    Owings Mills, MD 21117

You may also complete a CMS Complaint Form to file a complaint.

You can also Contact Us to get the aggregate numbers of grievances, appeals and exceptions filed with us; to question processes; or to ask about the status of a previously submitted grievance, appeal or exception. 

The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your grievance. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we do not accept your grievance in the whole or in part, our written decision will explain why it was not accepted, and will tell you about any dispute resolution options you may have.

Whether you call or write, you should contact Member Services right away. The grievance must be made within 60 calendar days after you had the problem you want to complain about.

If you are making a grievance because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” grievance. If you have a “fast” grievance, it means we will give you an answer within 24 hours.

Effective January 1, 2022 to file a grievance you can do the following:

Phone:

Contact customer service for any requests including making an oral request to Coverage Determination and Appeals. Our customer service team is available 24/7/365 at 1-844-786-6762 (TTY: 711). Other means of contact are provided below.

Fax: 1-866-217-3353

Mail:
Grievance Department
P.O. Box 30016
Pittsburgh, PA 15222-0330

You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at: www.Medicare.gov/MedicareComplaintForm/home.aspx

The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your grievance. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we do not accept your grievance in the whole or in part, our written decision will explain why it was not accepted and will tell you about any dispute resolution options you may have.

How to appoint someone to act on your behalf

You or your physician may request an initial determination or file a grievance or appeal. You may name a relative, friend, advocate, doctor or anyone else as your “appointed representative” to act for you. You may already have a representative authorized under State law to act for you; however, if you want someone to act for you, you and your representative must sign and date a statement giving the person legal permission to be your appointed representative. The form is available below. Please contact your plan for more information.

Appointment of Representative Form