CurrentAmeriHealthPolicy Y0041_H5361_AH_C_24_113744

Request for Redetermination of Medicare Prescription Drug Denial

This document governs the process for Medicare Part D enrollees (and their authorized representatives or prescribers) to request a redetermination (appeal) after AmeriHealth PPO denies coverage or payment for a prescription drug. It describes who may file, timelines, submission methods, and information to include.

Policy Summary

PayerAmeriHealth

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy Y0041_H5361_AH_C_24_113744

Change TypeInformational — no material changes

Effective Date

Next Review Date

Key ActionPrescriber may request an appeal on an enrollee's behalf and provide a supporting statement to obtain an expedited decision.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daystimeframe to request a redetermination

72 hoursexpedited decision timeframe

7 daysstandard decision waiting period

1-888-289-3008appeals fax

PO Box 13652mailing address

Redetermination Submission Requirements & Timelines

Submission requirements and timelines

Information and requirements to submit a redetermination request:

Who may file: The enrollee, the enrollee's prescriber on the enrollee's behalf, or another individual who has been designated as the enrollee's representative (contact AmeriHealth to learn how to name a representative).

Timeframe: Request must be submitted within 60 days from the date of the Notice of Denial of Medicare Prescription Drug Coverage.

Submission methods: By mail to AmeriHealth PPO Medicare Member Appeals Unit, PO Box 13652, Philadelphia, PA 19101-3652; by fax to 1-888-289-3008; via the AmeriHealth Medicare website; or by phone for expedited requests at 1-866-569-5190 (TTY/TDD: 711).

Required information to include with the request: name of the prescription drug, strength/quantity/dose, whether the drug was purchased pending appeal (if yes, date purchased, amount paid and receipt), and name and telephone number of the pharmacy.

Policy Summary

PayerAmeriHealth

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy Y0041_H5361_AH_C_24_113744

Change TypeInformational — no material changes

Effective Date

Next Review Date

Key ActionPrescriber may request an appeal on an enrollee's behalf and provide a supporting statement to obtain an expedited decision.

SourceLink

On This Page

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Prescriber-Initiated Appeals and Expedited Support

Prior Authorization

Prescriber-initiated appeals and expedited support

A prescriber may file an appeal on an enrollee's behalf and may provide a supporting statement to request an expedited (72-hour) decision when waiting 7 days for a standard decision could seriously harm the enrollee's life, health, or ability to regain maximum function. If the prescriber indicates that waiting 7 days could seriously harm the enrollee's health, AmeriHealth will automatically issue a decision within 72 hours; if prescriber support is not provided, the Plan will determine whether a fast decision is required.

Who may file: “Your prescriber may ask us for an appeal on your behalf.” [[chunk 0]]
Expedited request: attach prescriber’s supporting statement and check the expedited box; with prescriber support the decision will be made within 72 hours. [[chunk 3]]
If no prescriber support: the Plan will decide whether the case merits an expedited review. [[chunk 3]]

Key Terms

inv-03: redetermination — definition

DefinitionA redetermination is an appeal you may request when AmeriHealth PPO denies coverage or payment for a Medicare prescription drug; it is a review of the denied decision.

Who may requestYou, your prescriber on your behalf, or an authorized representative may file a redetermination within the allowed timeframe.

Timeframe to fileYou have 60 days from the date of the Notice of Denial of Medicare Prescription Drug Coverage to request a redetermination.

How to submitSubmit the redetermination form by mail, fax, or online via the AmeriHealth Medicare website; fax number and mailing address are provided on the form.

Contact info for submissionsMail: AmeriHealth PPO Medicare Member Appeals Unit PO Box 13652 Philadelphia, PA 19101-3652; Fax: 1-888-289-3008; online at www.amerihealthmedicare.com.

inv-04: expedited appeal — definition and conditions

DefinitionAn expedited (fast) decision is a quicker review granted when waiting the standard 7 days could seriously harm the enrollee's life, health, or ability to regain maximum function.

Prescriber supportIf the prescriber indicates that waiting 7 days could seriously harm the enrollee, the Plan will automatically issue a decision within 72 hours — attach the prescriber's supporting statement to the request.

Plan discretion without prescriber statementIf you do not obtain your prescriber's support, the Plan will decide whether the case qualifies for an expedited decision.

RestrictionsYou cannot request an expedited appeal to obtain reimbursement for a drug you have already received.

How to request expeditedExpedited appeal requests can be made by phone at 1-866-569-5190 (TTY/TDD: 711) or indicated on the form with supporting prescriber documentation.