CurrentModa HealthPolicy N/A

Medicare prescription drug redetermination (appeal) request form

Governs the process by which Moda Health Medicare enrollees (or their authorized representatives) may request a redetermination (appeal) of a denied prescription drug coverage or payment decision. Applies to Medicare prescription drug members of Moda Health Plan, Inc.

Policy Summary

PayerModa Health

PolicyMedicare prescription drug redetermination (appeal) request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a redetermination request within 60 days of the Notice of Denial by mail, fax (503-412-4003), website, or phone for expedited requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daystime to request redetermination from date of Notice of Denial

72 hourstarget turnaround for expedited appeals

7 daysstandard decision timeframe

1-866-796-3221expedited phone

503-412-4003fax to submit form

Redetermination Request Requirements

Redetermination request requirements

Procedure to request redetermination and information to include on the request form:

Submit the redetermination request within 60 days of the date of the Notice of Denial.

Form may be mailed, faxed, or submitted via website; expedited requests can be made by phone.

Include enrollee identifying information.

Provide enrollee name, date of birth, address, phone, and enrollee ID as requested on the form.

If the requestor is not the enrollee, provide requester/representative information and documentation of authority.

Include documentation such as CMS-1696 or equivalent if representation was not previously submitted.

ALL of the following

Policy Summary

PayerModa Health

PolicyMedicare prescription drug redetermination (appeal) request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a redetermination request within 60 days of the Notice of Denial by mail, fax (503-412-4003), website, or phone for expedited requests.

SourceLink

On This Page

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How to Request & Expedited Process

Note

How to Request Redetermination

You have 60 days from the date of our Notice of Denial of Medicare Prescription Coverage to request a redetermination (appeal). Submit your request by mail, fax, or online. Mail: Moda Health Plan, Inc., Attn: Appeals, P.O. Box 40384, Portland, OR 97240-0384. Fax: 503-412-4003. Website: www.modahealth.com/medicare. Expedited appeal requests may be made by phone at 1-866-796-3221.

Submit within 60 days of Notice of Denial
Mail: Moda Health Plan, Inc., Attn: Appeals, P.O. Box 40384, Portland, OR 97240-0384
Fax: 503-412-4003
Online: www.modahealth.com/medicare
Phone for expedited requests: 1-866-796-3221

Prior Authorization

Expedited Appeal Process

If waiting up to 7 days for a standard decision could seriously jeopardize the enrollee's life, health, or ability to regain maximum function, the enrollee or prescriber may request an expedited (fast) appeal. If the prescriber indicates that waiting could seriously harm the enrollee, Moda will automatically decide the appeal within 72 hours. If the prescriber does not support expedited review, Moda will evaluate whether the case nonetheless meets the criteria for an expedited decision. Expedited appeals are not available for requests that seek reimbursement for a drug already received.

72-hour target turnaround when prescriber supports medical urgency
Expedited request may be initiated by enrollee, prescriber, or representative
Not applicable for reimbursement requests for drugs already received
Attach prescriber statement or supporting medical records with the request when possible

Documentation Required

Representative Documentation

If someone other than the enrollee (for example, a family member, friend, prescriber, or other individual) submits the appeal request, documentation of authority to act on the enrollee's behalf must be provided. Acceptable documentation includes a completed CMS-1696 Authorization to Disclose Personal Health Information and Request Representational Assistance form or a written equivalent that clearly shows the enrollee's appointment of the representative. If this documentation was not submitted at the coverage determination level, include it with the redetermination request. For more information on appointing a representative, contact the plan or 1-800-Medicare.

Attach completed CMS-1696 or written equivalent if representative is submitting the request
If CMS-1696 was provided at coverage determination level, resubmission is not required
Contact the plan or 1-800-Medicare for assistance naming a representative

Key Definitions

inv-07: Expedited appeal definition

DefinitionAn expedited (fast) decision is an appeal processed within 72 hours when the prescriber indicates that waiting 7 days for a standard decision could seriously harm the enrollee's life, health, or ability to regain maximum function.

Condition to requestYou or your prescriber must believe that waiting 7 days could seriously harm the enrollee; check the box on the form to request expedited review.

Prescriber supportIf the prescriber indicates waiting would seriously harm the enrollee, Moda will automatically issue a decision within 72 hours; if not, Moda will determine whether a fast decision is required.

LimitationExpedited appeals cannot be used to request reimbursement for a drug already received.

inv-08: Representative

DefinitionRepresentative: an individual authorized to act on behalf of the enrollee when submitting a redetermination request.

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

When to complete requestor sectionComplete the requestor information section of the form only if the person making the request is not the enrollee (name, relationship, address, phone, etc.).

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

OpenPayer

Medicare prescription drug redetermination (appeal) request form

Redetermination Request Requirements

Coding / Transaction Details

How to Request & Expedited Process

Key Definitions