CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Request for Redetermination of Medicare Prescription Drug Denial

Form and instructions for enrollees (or their representatives) to appeal a denial of Medicare prescription drug coverage and request a redetermination from the plan.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeAdministrative — informational update

Effective DateN/A

Next Review DateN/A

Key ActionEnrollees or prescribers may request a redetermination within 60 days; expedited requests by phone for a 72-hour decision when prescriber indicates waiting 7 days could seriously harm the enrollee.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daystimeframe to request redetermination from date of Notice of Denial

72 hoursdecision time for expedited appeals

7 daysstandard decision wait period

1-888-403-3398expedited appeal phone

1-877-239-4565fax for redetermination form

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Submission & Evidence Requirements for Redetermination

Submission Criteria for Redetermination

Information and evidence required to support a redetermination request:

ALL of the following

Enrollee name
Date of birth
Enrollee address
Member ID

ALL of the following

Requestor name
Requestor relationship to enrollee
Requestor address and phone
Documentation authorizing the representative (Authorization of Representation Form CMS-1696 or equivalent)

ALL of the following

Name of drug
Strength, quantity, and dose
Purchase pending appeal
- Indicate whether drug was purchased pending appeal (Yes/No)
- If Yes: date purchased
- If Yes: amount paid (attach copy of receipt)
Name and telephone number of pharmacy

ALL of the following

Prescriber's name and contact information
Supporting statement from prescriber addressing why enrollee cannot meet the Plan's coverage criteria and why alternate drugs are not medically appropriate (attach if available)

Expedited decision request

Check the box if you believe you need a decision within 72 hours and attach prescriber's supporting statement if available
If prescriber indicates that waiting 7 days could seriously harm the enrollee, the plan will automatically issue a decision within 72 hours
If no prescriber support is provided, the plan will determine whether the case requires an expedited decision
Note: expedited requests cannot be used to request reimbursement for a drug already received

ALL of the following

Explanation of reasons for appealing (attach additional pages if necessary)
Any additional information believed to help the case, such as relevant medical records
Refer to the Notice of Denial and have prescriber address the Plan's stated coverage criteria if available

ALL of the following

You have 60 days from the date of the Notice of Denial of Medicare Prescription Drug Coverage to ask for a redetermination
Form may be sent by mail to Optum Rx c/o Appeals Coordinator P O Box 2975 Mission, KS 66201 or by fax to 1-877-239-4565
Expedited appeal requests can be made by phone at 1-888-403-3398

How to Request Redetermination and Expedited Appeals

Denial Risk

Expedited decision criteria and 72-hour timeframe

If the prescriber states that waiting 7 days for a standard decision could seriously harm the enrollee’s life, health, or ability to regain maximum function, the plan will automatically issue a decision within 72 hours. If no prescriber support is provided, the plan will determine whether the case requires an expedited decision.

Prescriber must indicate that waiting 7 days could seriously harm the enrollee to trigger automatic 72-hour decision
If prescriber support is not obtained, the plan will decide whether a fast decision is warranted
Expedited appeals are not available for requests seeking reimbursement for a drug already received

Key Definitions

Representative

DefinitionRepresentative — an individual authorized to act on the enrollee's behalf as documented by Authorization of Representation Form CMS-1696 or a written equivalent.

When to completeComplete the representative section only if the person making the request is not the enrollee (provide requestor name, relationship, address, phone).

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

Help and questionsFor more information on appointing a representative, contact your plan or 1-800-Medicare.

Expedited Appeal

Definition