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Drug Coverage Determination, Appeals and Exceptions

What is the process for requesting an appeal regarding my drug coverage?
How do I request a coverage determination/medical exception for a drug?
How do I request preauthorization for a drug?
What is a grievance and how do I file one?

What is the process for requesting an appeal regarding my drug coverage?

Within 60 calendar days from the date of the coverage notice, a member, a member’s authorized representative or a physician may request an appeal either by phone, in person, in writing or by fax. (There are no specific appeal forms. However, for speedy appeals processing, an Appointment of Representative form will need to be completed when someone other than the member appeals). The prescribing physician cannot request a standard appeal without being the appointed representative. The prescribing physician, however, can request an expedited appeal.

If the requesting party misses the 60-day appeal time frame, the appeal still will be processed if a reasonable explanation as to why the deadline was not met is received. If an urgent appeal is registered after business hours, a message may be left on the Member Relations phone line (1-800-500-3373) and the call will be returned the same day. 

The party filing the appeal has the right to include in the appeal any additional information, evidence, pertinent facts or laws.

A Medical Director/Clinical peer who was not involved in the treatment of the member, did not make the initial coverage decision, is not a subordinate of the initial reviewer and possesses the appropriate level of training and expertise will evaluate the necessity of the pharmaceutical request. 

Time Frames:

  • Standard appeal: We’ll make a decision within seven calendar days from the date the appeal is received.
  • Expedited appeal: We’ll make a decision within 72 hours from the date the appeal is received.
    An expedited appeal is based on the urgency of the member’s heath condition. Evidence of a member’s condition can be demonstrated by the treating physician or the member’s health records. Health Alliance will automatically expedite a request if it determines, or an enrollee’s prescribing physician indicates, that applying the standard time frame could seriously jeopardize the life or health of the member.

No extensions may be taken for the review time frame. Health Alliance must make a reasonable and diligent effort to obtain all information needed to make the decision. 

If either time frame is not met, Health Alliance must notify the member that the complete appeal file is being forward to an Independent Review Organization and that he or she has the right to still submit additional evidence pertinent to the case.

When the decision has been made, a representative will inform the member the same day the decision is made both verbally and in writing. If the request is still denied, the member will be informed of the process for filing an appeal with the Independent Review Organization. 

Contact information:

To file an appeal, or to check on the status of an appeal, you may contact us at:

Member Relations Department

301 S. Vine St.

Urbana, IL 61801

 

Phone: 1-800-500-3373
 TTY/TDD: 1-877-486-2048
 Fax: (217) 337-8009

How do I request a coverage determination/medical exception for a drug?

You, your authorized representative or your prescribing physician may request a coverage determination in writing using our Coverage Determination Request form. Urgent requests may be submitted by telephone as well. You may also request coverage determination by completing the Medicare Prescription Drug Determination Request Form (for enrollees) or the Medicare Part D Coverage Determination Request Form (for providers). Urgent requests may be submitted by telephone as well.  

Prescribing physicians have an important role in the coverage/exceptions process. Whenever a member requests a formulary or tiering exception, the prescribing physician must provide the Health Alliance Pharmacy Department with a written statement to support the exception request.

Information required when requesting a medical exception includes:

  • Member name and Health Alliance member number
  • Physician name, address and phone number
  • Drug name and strength
  • Member diagnosis
  • Chart documentation of previous medical history pertaining to the requested drug
  • Pharmacy name and phone number
  • Physician’s statement of support
Time Frames:

  • Standard coverage/exception request: 72 hours from receipt of request or for an exception request, from receipt of the physician’s supporting statement.
  • Expedited coverage/exception request: 24 hours from receipt of request or for exception request, from receipt of the physician’s supporting statement.

Contact information:

To submit a coverage determination request, to check the status of a request or to provide additional information (including a supporting statement from your physician) about a request, you may contact us at:


Health Alliance

Pharmacy Department

301 S. Vine St.

Urbana, IL  61801-3347

 

Phone: 1-800-851-3379, extension 8048
Fax: (217) 255-4598

How do I request preauthorization for a drug?

The process for requesting preauthorization for a drug is the same as the process for requesting a coverage determination. Please refer to the question, “How do I request a coverage determination/medical exception for a drug?”

What is a grievance and how do I file one?

A grievance is defined as any complaint or dispute, other than one that involves a coverage determination that expresses dissatisfaction with any aspect of the operations, activities or behavior of the health plan. Examples of grievances include, but are not limited to:

  • timeliness, appropriateness, access to and/or setting of services provided by the health plan
  • concerns about waiting times
  • demeanor of pharmacy or customer services staff
  • disputes concerning the timeliness or accuracy of filling a prescription
A complaint may include both grievances and coverage determinations. When this happens, each issue will be processed separately and simultaneously under the proper procedures.

A member/appointed representative may file a grievance with the health plan either verbally or in writing no later than 60 days after the event or incident that precipitates the grievance. If a grievance is filed in writing, the response to the grievance will also be provided in writing. A grievance submitted verbally can be responded to either verbally or in writing, unless the member requests a written response. All grievances related to quality of care, regardless of how the grievance is filed, will be responded to in writing. The response for quality of care issues will also describe to the member the right to file a written complaint with the Quality Improvement Organization (QIO).

The health plan will accept any information or evidence concerning the grievance. The health plan will notify the member and all concerned parties, as expeditiously as the member’s case requires, based on the member’s health status, but not later than 30 days after the health plan receives the verbal or written grievance. The health plan may extend the 30-day standard response time frame by up to 14 days if the member requests the extension or the health plan justifies the need for additional information. If an extension is taken the member will be immediately notified in writing of the reason(s) for the delay.

In addition, the health plan will respond within 24 hours to an expedited grievance that the health plan refused to grant a request for an expedited coverage determination or expedited redetermination, as long as the member has not received the drug in dispute.

Time Frames:

  • Expedited: 24 hours from date of receipt.
  • Standard: 30 days from date of receipt.
  • Extension: 14 days with proper cause.

Contact information:
To file a grievance, or to check on the status of a grievance, you may contact us at:

Health Alliance

Member Relations Department

301 S. Vine Street

Urbana, IL  61801-3347

 

1-800-500-3373

TTY/TDD: 1-877-486-2048

Fax: (217) 337-8009

You may view "What to do if you have a problem or complaint (coverage decisions, appeals, complaints)" of the Evidence of Coverage booklet for further information on these process. Request for Medicare Prescription Drug Determination Request Form (for use by enrollees) located at http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/ModelCoverageDeterminationRequestForm.pdf Medicare Part D Coverage Determination Request Form (for use by provider) located at http://www.cms.hhs.gov/MLNProducts/Downloads/Form_Exceptions_final.pdf.