Currentblue cross blue shield - michiganPolicy N/A

Request for Redetermination of Medicare Prescription Drug Denial

This document governs the process and form for beneficiaries and prescribers to request a redetermination (appeal) of BCN Advantage Medicare prescription drug coverage denials; it affects plan enrollees, prescribers, and authorized representatives.

Policy Summary

Payerblue cross blue shield - michigan

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed appeal form and supporting information by fax or mail to the BCN Advantage Clinical Pharmacy Help Desk.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

65appeal filing deadline (days)

72 hrsexpedited decision timeline

7 daysstandard wait period

1-800-437-3803phone for appeals

1-800-459-8027fax to submit form

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Documentation and Evidence Needed for Redetermination

Required documentation and rationale

Information and evidence required to support a redetermination request

Required attachments

Include a copy of the Notice of Denial of Medicare Prescription Drug Coverage.
Supporting clinical information (one or more)
- Statement from the prescriber explaining why the enrollee cannot meet the plan's coverage rules and/or why the plan's required drugs are not medically appropriate for the enrollee.
- Relevant medical records that support medical necessity or the prescriber's rationale.
Additional documentation (if applicable)
- Receipt and proof of purchase if the enrollee already purchased the drug (include date purchased and amount paid).
- Pharmacy information (name and phone number) when relevant to the request.

Prescription & prescriber information

Name of the drug requested, including strength/quantity/dose.
Prescriber name, office address, city/state/ZIP, office phone and fax, and office contact person.
Indication whether the drug was already purchased (Yes/No); if Yes, include date purchased, amount paid and attach a copy of the receipt.

Authorization to file or expedited handling

If someone other than the enrollee or prescriber files the appeal, documentation that the filer is the enrollee's designated representative (see representative instructions).
If an expedited (fast) decision is requested, check the expedited box on the form and include a prescriber supporting statement that waiting up to 7 days could seriously harm the enrollee's life, health, or ability to regain maximum function to support a 72-hour decision.

Submission instructions

Attach all supporting information you think may help your case (e.g., prescriber statement, medical records).
Follow form submission instructions (fax or mail to the BCN Advantage Clinical Pharmacy Help Desk as provided on the form).

Codes and Deadlines

No billing or procedure codes providedmixed

Appeal filing deadline

Filing deadlineYou may ask for an appeal within 65 days of the date of our Notice of Denial of Medicare Prescription Drug Coverage.

Online filing optionYou can also file an appeal through our website at https://www.bcbsm.com/medicare/resources/formsdocuments/manage-account/pdp-complaints-callback/.

Phone assistanceExpedited appeal requests can be made by phone at 1-800-437-3803 (TTY users call 711).

How to Submit Appeals and Expedited Requests

Prior Authorization

Prescriber appeals and expedited requests

Prescribers may submit an appeal on behalf of the enrollee. Expedited (fast) decision requests can be made by phone; if the prescriber provides a supporting statement that waiting 7 days could seriously harm the enrollee’s life, health, or ability to regain maximum function, BCN Advantage will automatically issue a decision within 72 hours. If the prescriber does not support an expedited request, BCN Advantage will decide whether a fast decision is warranted.

Prescriber may file the appeal for the enrollee (call 1-800-437-3803 for assistance).
Expedited requests may be made by phone at 1-800-437-3803 (TTY 711).
A prescriber’s supporting statement that waiting 7 days could seriously harm the enrollee triggers an automatic 72-hour decision.

Documentation Required

Submit completed form and supporting documentation

Fax or mail the completed Request for Redetermination form and any supporting information to the BCN Advantage Clinical Pharmacy Help Desk. A fax number is provided for submission.

Mailing address: BCN Advantage Clinical Pharmacy Help Desk - MC 512J, PO Box 441877, Detroit, MI 48244.
Fax Number: 1-800-459-8027.

Representative and Expedited Appeal Definitions

Representative (definition)

Who may be a representativeA person other than the enrollee or the enrollee's prescriber who is authorized to act on the enrollee's behalf.

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

How to appoint or learn moreCall BCN Advantage at 1-800-437-3803 (TTY 711) for information on naming a representative.

Expedited appeal (definition and timing)

Expedited decision timingA decision issued within 72 hours when an expedited request is approved.

Criteria to requestCheck the box if you believe you need a decision within 72 hours and attach a supporting statement from your prescriber indicating that waiting 7 days could seriously harm your life, health, or ability to regain maximum function.

Automatic expedited handlingIf your prescriber indicates that waiting 7 days could seriously harm your health, BCN will automatically give you a decision within 72 hours.

No expedited for retrospective requestsYou cannot ask for an expedited appeal if you are asking to be paid back for a drug you already got.