CurrentFidelis CarePolicy N/A

Request for Redetermination of Medicare Prescription Drug Denial

Form and instructions for Medicare members (Wellcare by Fidelis Care) to appeal (request redetermination) denials of prescription drug coverage; affects enrollees, prescribers, and authorized representatives.

Policy Summary

PayerFidelis Care (Wellcare by Fidelis Care)

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMembers, prescribers, or authorized representatives may request a redetermination within 65 days of the Notice of Denial; expedited requests are eligible for a 72-hour decision with prescriber support.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

65 daystimeframe to request an appeal

72 hoursexpedited decision timeframe

1-800-247-1447Member Services

TTY 711TTY

1-866-388-1766Fax to submit appeal

Redetermination and Review Criteria

Redetermination procedural criteria

Procedural requirements and conditions to request redetermination or an expedited review.

ALL of the following

Appeal must be filed within 65 days of the date of the Notice of Denial.

Who may file

The enrollee may file the appeal.
The enrollee's prescriber may file the appeal on the enrollee's behalf.
An authorized representative may file the appeal after being named as the enrollee's representative (contact Member Services for instructions).

Policy Summary

PayerFidelis Care (Wellcare by Fidelis Care)

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Expedited (fast) decision criteria

Member (or prescriber) believes that waiting 7 days for a standard decision could seriously harm life, health, or ability to regain maximum function.
If the prescriber provides a supporting statement indicating that waiting 7 days could seriously harm the enrollee's health, the plan will automatically decide within 72 hours.
If the prescriber does not support an expedited request, the plan will determine whether the case requires a fast decision; expedited requests are not available for requests seeking reimbursement for a drug already received.

How to Request a Redetermination

Prior Authorization

Appeal request actions and timelines

Members, prescribers, or authorized representatives may request a redetermination (appeal) of a Medicare prescription drug coverage denial within 65 days of the date of the Notice of Denial. Appeals can be filed online at www.fideliscare.org/wellcaremedicare, by calling Member Services at 1-800-247-1447 (TTY 711), or by submitting the form with supporting documentation. Expedited (fast) requests may be made if waiting 7 days could seriously harm the enrollee's life, health, or ability to regain maximum function; if the prescriber supports expedited review, the plan will automatically decide within 72 hours. Prescribers may file on the enrollee's behalf; representatives must be named per Member Services instructions.

File within 65 days of the Notice of Denial (standard timeframe).
Submit via website: www.fideliscare.org/wellcaremedicare, or call Member Services 1-800-247-1447 (TTY 711).
Expedited requests: prescriber support → decision within 72 hours; if no prescriber support, plan will determine urgency.
Attach supporting documents: prescriber statement, medical records, and the Notice of Denial; include receipts if drug already purchased.
Prescribers can file for the enrollee; to have another person act, name a representative through Member Services.

Key Terms

Expedited appeal — Expedited (fast) decision

Decision timeframeExpedited decisions are made within 72 hours when criteria are met.

When to requestCheck the expedited box and attach a prescriber statement if you believe waiting 7 days for a standard decision could seriously harm life, health, or ability to regain maximum function.

Prescriber-supported casesIf the prescriber indicates waiting 7 days could seriously harm the enrollee, the plan will automatically give a decision within 72 hours.

Plan-determined urgencyIf prescriber support is not provided, the plan will decide whether the case requires an expedited (fast) decision.

LimitationAn expedited appeal cannot be requested to obtain payment reimbursement for a drug already obtained by the enrollee.

Representative — Authorized representative and documentation

DefinitionAn authorized representative is a person making the request on behalf of the enrollee who must provide documentation showing authority to represent the enrollee.

Required documentationAttach a completed Form CMS-1696 or a written equivalent if it was not submitted at the coverage determination level.

When to complete sectionComplete the Representative section only if the person making the request is not the enrollee or the enrollee's prescriber.

Assistance contactFor information on appointing a representative, call Member Services at 1-800-247-1447 (TTY 711).