CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Medicare Prescription Drug Denial Redetermination (Appeal) Form

Governs the process and form for requesting a redetermination (appeal) of a Medicare prescription drug coverage denial from Blue Cross Blue Shield of Michigan. Applies to plan enrollees, their prescribers, and authorized representatives seeking reconsideration of a denied drug coverage or payment.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyMedicare Prescription Drug Denial Redetermination (Appeal) Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber or enrollee may request a redetermination; prescriber can file on behalf of enrollee and may trigger a 72-hour expedited decision if waiting could seriously harm the enrollee.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

65 daysfile timeframe (from Notice of Denial)

72 hoursexpedited decision timeframe

7 daysstandard decision reference

1-800-437-3803appeals phone (TTY 711)

1-866-601-4428

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Submission Requirements for Redetermination

Submission Requirements

Required information and supporting documentation to submit a redetermination request:

ALL of the following

Enrollee name
Member ID
Date of birth
Mailing address
Phone

ALL of the following

Name of drug requested
Strength, quantity, and dose
Prescriber name
Prescriber office address, phone, fax, and contact person
If already purchased
- Indicate drug was purchased
- Date purchased
- Amount paid

ALL of the following

Copy of the Notice of Denial of Medicare Prescription Drug Coverage
Prescriber statement or medical records explaining why plan coverage rules cannot be met or why plan drugs are not medically appropriate
Optional additional information
- Other information you think may help the case

ALL of the following

If person making request is not the enrollee or the enrollee's prescriber, provide representative documentation (e.g., Form CMS-1696 or equivalent)

ALL of the following

Mail to: Blue Cross Blue Shield of Michigan Clinical Pharmacy Help Desk - MC 512J, PO Box 441877, Detroit, MI 48244
Fax to: 1-866-601-4428
File online via: https://www.bcbsm.com/medicare/resources/formsdocuments/manage-account/pdp-complaints-callback/
For expedited (72-hour) decision requests or questions call: 1-800-437-3803 (TTY 711)

How to Request an Appeal / Expedited Appeal

Prior Authorization

How to Request an Appeal / Expedited Appeal

A redetermination (appeal) may be requested by the enrollee or the prescriber; the prescriber may file on the enrollee's behalf. Expedited (fast) appeals may be requested when waiting for a standard decision could seriously harm the enrollee, and a prescriber's supporting statement will trigger an automatic 72-hour decision. Expedited requests can be made by phone at 1-800-437-3803 (TTY 711).

You may ask for an appeal within 65 days of the date of the Notice of Denial of Medicare Prescription Drug Coverage. [[see cited chunks]]
If you or your prescriber believe waiting 7 days for a standard decision could seriously harm the enrollee's life, health, or ability to regain maximum function, you can ask for an expedited decision.
If the prescriber indicates that waiting 7 days could seriously harm the enrollee, Blue Cross Blue Shield of Michigan will automatically provide a decision within 72 hours.
Expedited appeal requests can be made by phone at 1-800-437-3803 (TTY users call 711).

Authorized Representative and Expedited Decision

Representative

DefinitionPerson authorized to act on behalf of the enrollee.

Required documentationAttach documentation showing authority to represent the enrollee (e.g., completed Form CMS-1696 or a written equivalent) if not previously submitted at the coverage determination level.

When to completeComplete representative section only if the person making the request is not the enrollee or the enrollee's prescriber.

Information to provideRepresentative name, relationship to enrollee, street address, city/state/ZIP, and phone.

Help / questionsCall 1-800-437-3803 (TTY 711) for more information on appointing a representative.

Expedited (fast) decision