CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Request for Redetermination of Medicare Prescription Drug Denial

Form and instructions for plan enrollees (or their prescribers/representatives) to request a redetermination (appeal) of a Medicare prescription drug coverage denial from Neighborhood INTEGRITY for Duals (HMO D-SNP). Applies to plan members seeking coverage or payment reconsideration for Part D drugs.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeAdministrative update (no material coverage changes)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed redetermination form with the Notice of Denial and supporting documentation (prescriber statement, medical records, and receipts if drug already purchased).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

65 daystimeframe to file an appeal from Notice of Denial

72 hourstarget for expedited decision

7 daysstandard decision wait period referenced for expedited criteria

1-844-812-6896phone for appeals (TTY 711)

1-855-633-7673

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Submission & Supporting Criteria for Redetermination

Submission and supporting criteria for redetermination

Documentation and rationale required to support redetermination requests

Include a copy of the Notice of Denial of Medicare Prescription Drug Coverage.

Provide a written explanation of why the drug should be covered; attach any additional information that may help the case (e.g., medical records).

Prescriber statement must explain why the enrollee cannot meet the plan's coverage rules and/or why plan‑required drugs are not medically appropriate.

If the drug was already purchased, attach a copy of the receipt and provide the date purchased and amount paid.

Expedited request criteria

Check the expedited (fast) decision box if waiting up to 7 days could seriously harm the enrollee's life, health, or ability to regain function.
Provide a supporting statement from the prescriber to request an expedited (72‑hour) decision.

If someone other than the enrollee or prescriber files the request, attach documentation of representative authority (e.g., Form CMS‑1696 or equivalent).

Documentation Threshold & Codes

Not applicablemixed

No procedure or billing codes provided in this form.

Evidence/documentation threshold for appeal

Required attachmentsInclude a copy of the Notice of Denial of Medicare Prescription Drug Coverage.

Clinical supportAttach a prescriber statement or medical records explaining why plan coverage rules can't be met or why plan-preferred drugs are not medically appropriate.

Receipts if already purchasedIf the drug was already purchased, attach a copy of the receipt and provide date and amount paid.

Appeal / Redetermination Process & Expedited Requests

Note

Provider/Enrollee Appeal Rights & How to Request a Redetermination

Request for Redetermination of Medicare Prescription Drug Denial Neighborhood INTEGRITY for Duals (HMO D-SNP) denied your request for coverage of (or payment for) your drug. You have the right to ask us for a redetermination (appeal) of our decision. Use this form to appeal this decision. - You may ask for an appeal within 65 days of the date of our Notice of Denial of Medicare Prescription Drug Coverage. - You can also file an appeal through our website at www.nhpri.org/INTEGRITYDuals. - Expedited appeal requests can be made by phone at 1-844-812-6896 (TTY 711). Your prescriber can ask us for an appeal on your behalf. If you want another person (like a family member or friend) to file an appeal for you, that person must be your representative. Call us at 1-844-812-6896 (TTY 711) to learn how to name a representative.

You may file an appeal within 65 days of the Notice of Denial of Medicare Prescription Drug Coverage.
Appeals may be filed online at www.nhpri.org/INTEGRITYDuals or by phone: 1-844-812-6896 (TTY 711).
Prescribers may file appeals on behalf of enrollees.
A designated representative (family member or friend) may file an appeal if properly named; call 1-844-812-6896 (TTY 711) for instructions.

Key Definitions

Expedited appeal

DefinitionExpedited appeal = request for a fast decision when waiting could seriously harm life, health, or ability to regain maximum function.

Standard expedited timingIf prescriber supports expedited request, decision will be made within 72 hours.

When to requestCheck the expedited box and attach a prescriber statement if you believe a 72-hour decision is needed; we may still review if prescriber support is absent.

Authorized representative

Who may serveA family member, friend, prescriber, or other person the enrollee appoints to file an appeal on their behalf.

Documentation requiredAttach proof of authority to represent the enrollee (e.g., completed Form CMS-1696 or written equivalent) if not already submitted at coverage determination level.