CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Request for Redetermination of Medicare Prescription Drug Denial

This form and instructions govern how enrollees in Neighborhood Health Plan of Rhode Island's INTEGRITY for Duals (HMO D-SNP) may request a redetermination (appeal) of a Medicare prescription drug coverage denial; it applies to plan enrollees, their prescribers, and authorized representatives.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescribers may submit an appeal on behalf of an enrollee and should include a supporting statement and medical records; prescriber support triggers expedited handling within 72 hours.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

65 daystimeframe to file a standard appeal

72 hoursexpedited decision target

7 daysstandard harm decision timeframe

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

Redetermination Submission Requirements

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Redetermination submission criteria

Requirements and materials to include with a redetermination request:

Completed enrollee information section (name, member ID, DOB, contact) or prescriber/representative details

Prescription and prescriber information including drug name, strength/quantity/dose, prescriber name and contact (office address, phone, fax, contact person), and pharmacy name and phone

If the drug was already purchased: date purchased, amount paid, and a copy of the receipt

A copy of the Notice of Denial of Medicare Prescription Drug Coverage

A written explanation of why the drug should be covered, including any supporting statement from the prescriber and relevant medical records describing why plan coverage rules cannot be met or why plan-required drugs are not medically appropriate

Expedited request pathway

Check the expedited decision box on the form if waiting could seriously harm the enrollee (request an expedited, fast decision)
Attach a prescriber supporting statement when requesting expedited review; prescriber support triggers an expedited decision (target 72 hours)

If someone other than the enrollee or the prescriber files the request, attach documentation of authority showing the filer is an authorized representative (e.g., CMS-1696 or equivalent)

Submission instructions: fax or mail the completed form and supporting information to CVS Caremark Part D Appeals and Exceptions, PO BOX 52000, MC109, Phoenix, AZ 85072-2000; fax 1-855-633-7673

ANY of the following

File a standard appeal within 65 days of the Notice of Denial of Medicare Prescription Drug Coverage
File an appeal online via the plan website www.nhpri.org/INTEGRITYDuals

For assistance or to request an expedited appeal by phone, call 1-844-812-6896 (TTY 711)

Enrollment in the INTEGRITY for Duals plan depends on contract renewal and the plan contracts with Medicare and Rhode Island Medicaid

Prescriber Submission and Expedited Requests

Prior Authorization

Prescriber-submitted appeals and expedited handling

Prescribers may submit an appeal (redetermination) on behalf of an enrollee; include a supporting statement from the prescriber and relevant medical records with the appeal. If the prescriber states that waiting 7 days for a standard decision could seriously harm the enrollee, the appeal will be handled on an expedited basis and a decision will be issued within 72 hours.

Attach prescriber statement and any relevant medical records to explain why plan coverage rules cannot be met or why formulary alternatives are not medically appropriate.
If you believe waiting 7 days could seriously harm the enrollee, check the expedited box and attach the prescriber’s statement; prescriber-supported expedited requests receive a decision within 72 hours.
Expedited requests can also be made by phone at 1-844-812-6896 (TTY 711).

Key Definitions

Expedited appeal — definition and timing

DefinitionExpedited appeal: an appeal process that yields a decision within 72 hours when waiting for a standard decision could seriously harm the enrollee's life, health, or ability to regain maximum function.

When to requestRequest expedited if you or your prescriber believe waiting 7 days for a standard decision could seriously harm life, health, or ability to regain maximum function.

Prescriber-supported automatic handlingIf the prescriber indicates that waiting 7 days could seriously harm the enrollee, the plan will automatically issue a decision within 72 hours.

How to requestCheck the expedited box on the form and attach a supporting statement from the prescriber when available; expedited requests may also be made by phone at 1-844-812-6896 (TTY 711).

LimitationsYou cannot request an expedited appeal to obtain reimbursement for a drug you have already received.

Representative — authorized person and documentation

Who is a representativeA person (e.g., family member or friend) authorized to act on the enrollee's behalf when filing an appeal.

Required documentationYou must attach documentation showing authority to represent the enrollee, such as a completed Form CMS-1696 or a written equivalent, if it was not submitted earlier.

When to complete representative infoComplete the Representative section only if the person making the request is not the enrollee or the enrollee's prescriber.

How to learn moreCall 1-844-812-6896 (TTY 711) for information on appointing a representative or required forms.