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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyUPMC Health Plan Medicare Drug Redetermination | O…
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    CurrentUPMC Health PlanPolicy N/A

    Request for Redetermination of Medicare Prescription Drug Denial

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    Form and instructions for UPMC for Life members to request a redetermination (appeal) of a Medicare prescription drug coverage denial; applies to UPMC for Life Medicare plan enrollees and their authorized representatives.

    Policy Summary
    PayerUPMC Health Plan
    PolicyRequest for Redetermination of Medicare Prescription Drug Denial
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionMembers or their prescribers may request a redetermination within 65 days of the Notice of Denial; prescribers can request expedited review by phone with supporting statement to obtain a decision within 72 hours.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    65 daysappeal filing timeframe
    72 hrsexpedited decision time
    7 daysstandard decision wait
    1-877-539-3080UPMC for Life HMO/PPO phone

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1-800-606-8648
    Complete Care phone

    Appeal Submission Criteria

    Appeal submission criteria

    Criteria and supporting information required for expedited and standard redeterminations

    ALL of the following

    • Appeal must be submitted within 65 days of the Notice of Denial or via the website/phone instructions provided on the Notice of Denial.

    Type of review requested

    • Request a standard redetermination (no expedited certification).
    • Member or prescriber may request an expedited (fast) decision if waiting 7 days for a standard decision could seriously harm life, health, or ability to regain maximum function; check the expedited box and attach a supporting statement from the prescriber.

    Expedited decision conditions

    • If the prescriber indicates that waiting 7 days could seriously harm the enrollee, the plan will automatically issue a decision within 72 hours.
    • If prescriber support is not provided, the plan will decide whether the case requires a fast decision.
    • An expedited appeal cannot be requested for reimbursement (asking the plan to pay you back for a drug you already received).

    Required supporting documentation

    • Include a copy of the Notice of Denial of Medicare Prescription Drug Coverage.
    • Attach any additional information that may help the case, such as a statement from the prescriber explaining why the plan's coverage rules cannot be met and/or why required formulary alternatives are not medically appropriate, and relevant medical records.
    • If seeking coverage or payment, include receipts or documentation if applicable (note: expedited requests cannot be for reimbursement of a drug already obtained).

    Filing by prescriber or representative

    • Prescribers may file appeals on behalf of enrollees and should provide the prescriber statement when requesting expedited review.
    • If a representative files the appeal, attach documentation of authority to represent the enrollee (e.g., CMS-1696 or written equivalent) if not previously provided.

    Coding and Deadlines

    No billing or clinical codes specifiedmixed
    No codes listed
    Appeal filing deadline — 65 days from Notice of Denial
    Filing deadlineAppeal must be filed within 65 days of the date of the Notice of Denial
    Alternate filing methodsAppeal can also be filed online at upmchealthplan.com/medicare/documents-and-forms
    Who may fileMember, prescriber, or an authorized representative may submit the appeal
    Contact for assistanceUPMC for Life HMO/PPO: 1-877-539-3080 (TTY: 711); Complete Care (HMO D-SNP): 1-800-606-8648 (TTY: 711)

    How to Request a Redetermination

    Prior Authorization

    How to request a redetermination and expedited appeals

    Members or their prescribers may request a redetermination (appeal) within 65 days of the date of the Notice of Denial. Expedited appeals can be requested by phone; if the prescriber certifies that waiting 7 days could seriously harm the enrollee, UPMC for Life will automatically decide the expedited appeal within 72 hours. Expedited requests without prescriber support will be evaluated to determine if a fast decision is warranted. Call the appropriate member phone line to request an expedited appeal (HMO/PPO: 1-877-539-3080; Complete Care HMO D-SNP: 1-800-606-8648).

    • Standard appeal filing timeframe: within 65 days of Notice of Denial.
    • Expedited appeals may be made by phone; prescriber statement triggers 72-hour decision.
    • If prescriber support is not provided, UPMC will determine whether expedited handling is appropriate.
    • Phone hours vary seasonally; see main form for hours of operation.
    Documentation Required

    Key Definitions

    Expedited appeal — definition and decision timeframe
    DefinitionAn expedited appeal is a request for a fast (expedited) decision when waiting could seriously harm the enrollee's life, health, or ability to regain maximum function.
    Prescriber supportIf the prescriber indicates waiting 7 days could seriously harm the enrollee, UPMC will automatically decide within 72 hours.
    Request methodExpedited appeal requests can be made by phone (see member phone numbers); attach prescriber statement to the request when available.
    LimitationsCannot request an expedited appeal to obtain reimbursement for a drug already received; if prescriber support is absent, UPMC will evaluate need for a fast decision.
    Representative documentation — required forms (e.g., CMS-1696) or written equivalent
    Required documentation
    Policy Summary
    PayerUPMC Health Plan
    PolicyRequest for Redetermination of Medicare Prescription Drug Denial
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionMembers or their prescribers may request a redetermination within 65 days of the Notice of Denial; prescribers can request expedited review by phone with supporting statement to obtain a decision within 72 hours.
    SourceLink
    On This Page
    Appeal Submission CriteriaCoding and DeadlinesHow to Request a RedeterminationKey Definitions

    Filing by prescriber or representative

    A prescriber may file an appeal on behalf of the enrollee. If someone other than the enrollee or the enrollee's prescriber files the appeal (a representative), documentation of authority to represent the enrollee—such as a completed Form CMS-1696 or a written equivalent—must be attached if it was not already provided at the coverage determination level.

    • Prescribers can submit the appeal for the enrollee directly.
    • Representatives must attach proof of authority (e.g., CMS-1696) unless previously submitted.
    Attach documentation showing authority to represent the enrollee (e.g., completed Form CMS-1696 or a written equivalent) if not already submitted at the coverage determination level.
    When to complete sectionComplete the Representative section only if the person making the request is not the enrollee or the enrollee's prescriber.
    How to appoint a representativeCall the phone number on page 1 for information on appointing a representative (member phone numbers provided in the Notice/form).
    Representative details requiredProvide representative name, relationship to enrollee, address, and phone number in the Representative section of the form.