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.
No material clinical or coverage changes in this revision.
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 codes listed |
How to Request a Redetermination
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.
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.
Key Definitions
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