CurrentIndependent HealthPolicy N/A

Request for Redetermination of Medicare Prescription Drug Denial

Form and instructions for Medicare Part D enrollees (or their prescribers/representatives) to appeal a denial of coverage or payment for a prescription drug from Independent Health.

Policy Summary

PayerIndependent Health

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeInformational — no coverage rule changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber may request an appeal on the enrollee's behalf and should provide a supporting statement for expedited requests explaining why plan rules cannot be met or why plan-required drugs are not medically appropriate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

65timeframe to file (days)

72 hrsexpedited decision time

7 daysstandard decision timeframe

Phone & onlinesubmission methods

Appeals and Redetermination Criteria

Policy Summary

PayerIndependent Health

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeInformational — no coverage rule 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.

Appeal must be filed within 65 days of the date of the Notice of Denial of Medicare Prescription Drug Coverage.

Submission methods

File online at www.independenthealth.com.
File by phone at (716) 250-4401 or 1-800-665-1502; expedited requests can be made by phone during specified hours (Oct 1–Mar 31: daily 8 a.m.–8 p.m.; Apr 1–Sep 30: Mon–Fri 8 a.m.–8 p.m.).
File using the redetermination form by mail or fax as provided on the form; TTY users call 711.

Expedited decision criteria

Request expedited (fast) decision if waiting up to 7 days for a standard decision could seriously harm the enrollee's life, health, or ability to regain maximum function.
Attach a supporting statement from the prescriber; if the prescriber indicates that waiting 7 days could seriously harm health, Independent Health will automatically issue a decision within 72 hours.
If there is no prescriber support for an expedited appeal, Independent Health will decide whether a fast decision is required.
An expedited appeal cannot be used to request reimbursement for a drug already obtained.

Supporting information to include

Include a copy of the Notice of Denial of Medicare Prescription Drug Coverage.
Attach any additional information such as medical records, receipts if applicable, and a statement from the prescriber explaining why plan coverage rules cannot be met or why plan-required drugs are not medically appropriate for the enrollee.
Provide any other information you believe may help the case.

Who may file and representative requirements

The enrollee may file the appeal personally.
The prescriber may request an appeal on the enrollee's behalf.
If someone other than the enrollee or prescriber files (e.g., family member or friend), that person must be the enrollee's representative; call Independent Health to learn how to name a representative.

Prescriber and Provider Responsibilities

Prior Authorization

Prescriber may file appeals and must provide supporting statement for expedited requests

A prescriber may file an appeal (redetermination) on the enrollee's behalf. For expedited (fast) requests, attach a supporting statement from the prescriber explaining why waiting up to 7 days for a standard decision could seriously harm the enrollee; if the prescriber indicates that waiting 7 days could seriously harm the enrollee, Independent Health will automatically issue a decision within 72 hours. The prescriber must explain why the enrollee cannot meet the plan's coverage rules and/or why plan‑required drugs are not medically appropriate, and any supporting medical records or the Notice of Denial should be included with the request.

Prescriber may request an appeal on the enrollee's behalf. (Chunk 0)
For expedited requests, attach a prescriber statement; if the prescriber attests waiting 7 days could seriously harm the enrollee, decision within 72 hours. (Chunk 3)
Prescriber must explain why plan coverage rules cannot be met and/or why plan‑required drugs are not medically appropriate; include Notice of Denial and any medical records. (Chunk 4)

Key Definitions

Expedited appeal

DefinitionExpedited appeal (fast decision) — request for a faster-than-standard decision when waiting 7 days could seriously harm the enrollee's life, health, or ability to regain maximum function.

Prescriber statementAttach a supporting statement from the prescriber explaining why waiting 7 days would cause serious harm; if prescriber indicates harm, decision will be made within 72 hours automatically.

Member request and plan reviewMember (or representative/prescriber) may request expedited review; if no prescriber support is provided, the plan will determine whether a fast decision is required.

LimitationsCannot request an expedited appeal for reimbursement (payment) for a drug already obtained.

Standard timeframe referenceExpedited requests are for cases where waiting the standard 7-day decision timeframe could cause serious harm; expedited decision target is 72 hours when criteria met.

Representative

DefinitionRepresentative — a person authorized to act on behalf of the enrollee when filing a request who is not the enrollee or the enrollee's prescriber.

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

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

Contact for questionsFor more information on appointing a representative, call (716) 250-4401 or 1-800-665-1502; TTY users call 711.

Required fields on formProvide representative name, relationship to enrollee, street address, city/state/ZIP, and phone number on the request form.