CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicare Part D prescription drug appeal request form

This document provides the form and instructions for members of Neighborhood Dual CONNECT (HMO D-SNP) to request an internal appeal (reconsideration) of a denial for Medicare Part D prescription drug coverage; it affects enrolled Dual CONNECT members, their prescribing providers, and authorized representatives.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicare Part D prescription drug appeal request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescribing provider may submit an appeal on behalf of the member by completing the form with prescriber and prescription details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

65 daystimeframe to file an appeal from date of denial notice

72 hoursexpedited (quick) decision turnaround when criteria met

7 daysstandard decision timeframe

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

1-855-633-7673fax to send completed form

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicare Part D prescription drug appeal request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescribing provider may submit an appeal on behalf of the member by completing the form with prescriber and prescription details.

SourceLink

On This Page

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Appeal Eligibility and Evidence Requirements

Appeal submission and evidence requirements

Conditions and evidence needed to support an appeal or expedited review:

ALL of the following

Include a prescriber statement or medical records as appropriate.
Attach a copy of the Medicare prescription drug coverage denial notice (Aviso de recusa).

ALL of the following

If the prescribing physician indicates that waiting 7 days may seriously jeopardize health, the plan will automatically provide a decision within 72 hours.
If there is no prescriber support for an expedited request, the plan will determine whether the case qualifies for a quick decision.

If someone other than the member or prescribing provider files the appeal, include documentation of authority to represent the member (e.g., CMS-1696 or equivalent).

Appeals must be submitted within 65 days of the date of the denial notice via the instructions on the form (mail or fax to CVS Caremark Part D Appeals).

See form for mailing address and fax number.

Prescription Details and Filing Deadlines

Prescription detailsmixed

Nome do medicamento solicitado	Nome do medicamento solicitado
Concentração/quantidade/dosagem	Concentração/quantidade/dosagem
Nome do médico prescritor	Nome do médico prescritor
Endereço do consultório	Endereço do consultório
Cidade, estado, código postal	Cidade, estado, código postal
Telefone do consultório	Telefone do consultório
Fax do consultório	Fax do consultório
Pessoa de contacto do consultório	Pessoa de contacto do consultório
Já adquiriu este medicamento?	Indicação se o medicamento já foi adquirido (Sim/Não)
Data de aquisição	Data de aquisição (se aplicável)

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Appeal filing deadline

Filing deadline65 days from date of denial notice

Submission methodsMail, fax, online at www.nhpri.org/DualCONNECT, or by phone

Phone for assistance1-844-812-6896 (TTY 711)

How Providers May Submit Appeals and Request Expedited Reviews

Note

Provider-submitted appeal

Prescribing provider may submit an appeal on behalf of the member using the member appeal form. The form collects prescriber contact information and prescription details (drug name, concentration/quantity/dosage), pharmacy and purchase information when applicable, and prescriber office contact details. If someone other than the prescriber will file the appeal (for example, a designated representative), the member must first authorize that representative; contact 1-844-812-6896 (TTY 711) for instructions.

Drug name, concentration/quantity/dosage
Prescriber name and office address
Prescriber office phone and fax
Prescriber office contact person
Whether member already obtained the drug; if yes: date acquired, amount paid, attach receipt, pharmacy name and phone

Prior Authorization

Expedited review process

Request an expedited (fast) review if waiting the standard 7 days for a decision could seriously jeopardize the member’s life, health, or ability to regain maximum function. The prescriber must include a supporting statement indicating that a 7‑day wait could cause such harm. When the prescriber states that waiting 7 days may seriously jeopardize the member’s health, Neighborhood will automatically process the appeal as a 72‑hour expedited review. Expedited requests may be submitted by phone at 1-844-812-6896 (TTY 711); include the prescriber’s statement and any supporting documentation with the request. Expedited reviews are not available for reimbursement requests for a medication the member already has.

Check the expedited review box on the form to request a 72‑hour decision
Attach prescriber’s supporting statement when requesting expedited review
Phone expedited requests: 1-844-812-6896 (TTY 711)
Expedited review not available for reimbursement requests for medications already in the member’s possession

OpenPayer

Medicare Part D prescription drug appeal request form

Appeal Eligibility and Evidence Requirements

Prescription Details and Filing Deadlines

How Providers May Submit Appeals and Request Expedited Reviews

Representative and Contact Information