CurrentModa HealthPolicy N/A

Request for Redetermination of Medicare Prescription Drug Denial

Provides instructions and form fields for Medicare enrollees (or their authorized representatives or prescribers) to request a redetermination (appeal) of a denied prescription drug coverage or payment decision by Moda Health Plan, Inc.; includes timelines, contact methods, and expedited appeal rules.

Policy Summary

PayerModa Health

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber may request an appeal on behalf of the enrollee; attach documentation (CMS-1696 or equivalent) when the requester is not the enrollee.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daystimeframe to request a redetermination

72 hoursexpedited decision timeframe

7 daysstandard decision reference

1-866-796-3221expedited phone

503-412-4003fax

Policy Summary

PayerModa Health

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber may request an appeal on behalf of the enrollee; attach documentation (CMS-1696 or equivalent) when the requester is not the enrollee.

SourceLink

On This Page

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Redetermination Submission Criteria

Procedural requirements and information to submit a redetermination (appeal) of a denied Medicare prescription drug coverage or payment decision.

Submission timeframe: Request must be submitted within 60 days from the date of the Notice of Denial of Medicare Prescription Drug Coverage.

Submission methods

Mail: send completed form to Moda Health Plan, Inc., Attn: Appeals, P.O. Box 40384, Portland, OR 97240-0384.
Fax: send to 503-412-4003.
Online: submit appeal via www.modahealth.com/medicare.
Expedited by phone: expedited appeal requests can be made by phone at 1-866-796-3221.

Who may request

Enrollee may request a redetermination.
Prescriber may request an appeal on the enrollee's behalf.
Another individual (e.g., family member or friend) may request an appeal only if they are the enrollee's authorized representative; contact Moda to learn how to name a representative.

Representation documentation: If someone other than the enrollee or the enrollee's prescriber requests the appeal, attach documentation showing authority to represent the enrollee (e.g., completed Authorization of Representative form or equivalent).

Expedited appeal criteria and process

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

Information to include with the request: Provide enrollee and prescriber contact information; drug name, strength, quantity, and dose; whether the drug was purchased pending appeal (include receipt, amount paid, date, and pharmacy contact if applicable); 설명 and supporting statements or medical records; signature and date of the person requesting the appeal.

Who May Make a Request & Representation

Note

Who May Make a Request

Your prescriber may request an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be designated as your representative.

Appeal request timeframe: 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage.
Prescriber may submit an appeal without additional documentation that names them as the prescriber.
If you need to name a different representative, contact Moda Health for instructions.

Documentation Required

Representation Documentation

If someone other than the enrollee or the enrollee's prescriber is requesting the appeal, attach documentation proving authority to represent the enrollee. Acceptable documentation includes a completed CMS-1696 Authorization of Representative form or a written equivalent if it was not already submitted at the coverage determination level. For more information on appointing a representative, contact your plan or 1-800-Medicare.

Attach CMS-1696 (Authorization of Representative) or written equivalent when applicable.
Submit documentation with the appeal if it was not provided at the coverage determination stage.
Contact Moda Health Appeals for questions: Fax 503-412-4003 or visit www.modahealth.com/medicare.

Key Definitions

Expedited appeal — definition and timing

DefinitionExpedited appeal: an appeal requested when waiting the standard 7 days for a decision could seriously harm the enrollee's life, health, or ability to regain maximum function.

Decision timeframe if expedited granted72 hours from receipt of the expedited request when the prescriber indicates waiting 7 days could seriously harm the enrollee.

Standard timeframe used to determine need7 days — used as the reference period; expedited available when waiting this long could cause serious harm.

How expedited requests are assessedIf the prescriber supports that waiting 7 days could seriously harm the enrollee, Moda will automatically give a decision within 72 hours; if no prescriber support, the plan will decide whether a fast decision is required.

LimitationsExpedited appeals are not available for requests seeking reimbursement for a drug already received.

Representative — definition and required Authorization of Representative Form

DefinitionRepresentative: an individual authorized to act on behalf of the enrollee to request an appeal.

Required documentationA completed Authorization of Representative Form CMS-1696 or a written equivalent must be attached if it was not submitted at the coverage determination level.

Who may serve as representativeAny individual (for example, a family member or friend) may be a representative if properly designated; prescribers may also request appeals on the enrollee's behalf.

How to appoint or get more informationContact the plan or 1-800-Medicare for more information on appointing a representative.