If you have a concern regarding a coverage decision, appeal or grievance related to your prescription drug (Part D) coverage, please call Member Services. Members of the HealthPartners® MSHO Plan (HMO SNP) should refer to this process.
If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from your HealthPartners plan or penalized in any way if you make a complaint. You can request the total number of HealthPartners grievances, appeals, and exceptions by contacting Member Services.
How to appoint a representative
You may appoint any individual (such as a relative, friend, advocate, attorney or physician) to act as your representative. Here’s more information on how to do so. You can also fill out this form from the Centers for Medicare and Medicaid Services.
What is a coverage decision (determination)?
A coverage decision (or coverage determination) is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. Examples of coverage decisions you can ask us to make about your Part D drugs:
- You ask us to make an exception, including:
- Asking us to cover a Part D drug that is not on the formulary
- Asking us to waive a restriction on coverage for a drug (such as limits)
- Asking to pay a lower cost-sharing amount for a covered non-preferred drug
- You ask us whether a drug is covered for you and if you satisfy any applicable coverage rules.
- You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.
If you disagree with a coverage decision we have made, you can appeal our decision (also known as requesting a redetermination).
For more information on asking for coverage decisions about your Part D prescription drugs, see the Evidence of Coverage for your plan (Chapter 9, Section 6 – Your Part D prescription drugs: How to ask for a coverage decision or make an appeal).
How to request a coverage decision
Step 1:
Request the type of coverage decision you want. To request a coverage decision or exception for your Part D prescription drug, please fill out or have someone acting on your behalf fill out the Coverage Determination Form. Or have your doctor fill out this form. You can return the form by fax or mail:
Fax:
952-853-8700 or 888-883-5434
Mail:
HealthPartners
Pharmacy Administration Department
P.O. Box 1309
Minneapolis, MN 55440-9463
You can also request a coverage decision or exception by calling 800-492-7259 between 8 a.m. and 8 p.m., seven days a week. TTY users call 952-883-6060 or 800-443-0156.
If your health status requires a fast (or expedited) decision, we will respond within 24 hours. For more details about fast decisions, see the Evidence of Coverage for your plan (Chapter 9, Section 6 – Your Part D prescription drugs: How to ask for a coverage decision or make an appeal).
Or
Log on to your myHealthPartners account to submit an Online Part D Coverage Determination or Redetermination request. Click on the 'Find a form' link on the Medical Plan Services tab, then scroll down to 'Medicare Forms' to begin.
If your health status requires a fast (or expedited) decision, we will respond within 24 hours. For more details about fast decisions, see the Evidence of Coverage for your plan (Chapter 9, Section 6 – Your Part D prescription drugs: How to ask for a coverage decision or make an appeal).
Step 2:
We will review your request and give you our answer.
- If you requested a standard decision about a drug you haven’t yet received, we must give you our answer within 72 hours.
- If you are requesting an exception, we will give you our answer within 72 hours of receiving your doctor’s statement supporting your request.
- If you requested a coverage decision about payment for a drug you already bought, we must give you our answer within 14 calendar days.
- If you requested a fast decision, and your situation meets certain requirements, we must give you our answer within 24 hours of your request.
Step 3:
If we say no to your coverage request, you have the right to request an appeal (redetermination).
What is an appeal (redetermination)?
A redetermination is any of the procedures that deal with the review of an unfavorable coverage determination. You would file a redetermination if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we’ll pay for a prescription drug. The form to request a redetermination is here.
How to file an appeal (redetermination)
Step 1:
You need to file your redetermination within 60 calendar days from the date included on the notice of our coverage determination. Please call us at the numbers shown listed below if you need help with filing your redetermination. You’ll receive a written response within seven days of a standard request and within 72 hours if an expedited appeal is granted. Your request will be reviewed by someone within our organization who was not involved in making the coverage determination. This helps ensure that we will give your request a fresh look.
You can mail your appeal to:
HealthPartners
P.O. Box 9463
Minneapolis, MN 55440-9463
Or fax it to us at 952-853-8742
Step 2:
If HealthPartners denies any part of your appeal, you or your appointed representatives have the right to ask an independent organization to review your case. This independent review organization contracts with the federal government and is not part of HealthPartners. You or your appointed representative must make a request for review by the independent review organization in writing within 60 calendar days after the date you were notified of the decision on your first appeal.
Step 3:
If the organization that reviews your case in Step 2 does not rule completely in your favor, you may ask for a review by an Administrative Law Judge. You must make a request for review by an Administrative Law Judge in writing within 60 calendar days after the date of the decision made at Appeal Level 2. The Administrative Law Judge will not review your appeal if the dollar value of the requested Part D benefit is less than $130*. If the dollar value is less than $130, you may not appeal any further.
Step 4:
Your case may be reviewed by the Medicare Appeals Council. The Medicare Appeals Council will first decide whether to review your case. There's no minimum dollar value for the Medicare Appeals Council to hear your case. If you got a denial at Step 3, you or your appointed representative can request review by filing a written request with the Council. The Medicare Appeals Council does not review every case it receives. When it gets your case, it will first decide whether to review your case. If they decide not to review your case, then you may request a review by a Federal Court Judge (see Step 5). The Medicare Appeals Council will issue a written notice advising you of any action taken with respect to your request for review. The notice will tell you how to request a review by a Federal Court Judge.
Step 5:
Your case may go to a Federal Court. In order to request judicial review of your case, you must file a civil action in a United States district court. The letter you get from the Medicare Appeals Council in Appeal Level 4 will tell you how to request this review. The Federal Court Judge will first decide whether to review your case.
If the contested amount is $1,300* or more, you may ask a Federal Court Judge to review the case.
*2011 amount. Amount changes annually.
If you or your provider have questions about your appeal, please contact HealthPartners. Members should call Member Services at 952-883-7979 or 1-800-233-9645. Providers (pharmacies and physicians) should call our Pharmacy Help Line at 952-883-5813 or 1-800-492-7259.
What is a grievance?
A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with HealthPartners Prescription Drug Plan or one of our network pharmacies that does not relate to coverage for a prescription drug. Grievances include quality and timeliness issues.
How to file a grievance
Step 1:
You may submit a grievance to Member Services either in writing or orally, no later than 60 days after the event. Member Services will make every effort to resolve the grievance. If the oral grievance is not resolved to your satisfaction within 10 calendar days of receipt of the grievance, we’ll offer to provide a grievance form to you, which must be completed and returned to Member Services for further consideration. If you would like assistance, we can help you fill out the form over the phone and then send it back to you for your signature.
You can mail your grievance request to:
HealthPartners
P.O. Box 9463
Minneapolis, MN 55440-9463
Step 2:
Member Services will investigate the grievance. We’ll notify you within 10 business days that we received the written grievance. We’ll contact you in writing of our decision within 30 days of receipt of the written grievance or grievance form. We may take up to an additional 14 days to notify you of the decision if you request the extension or if we justify a need for additional information and the delay is in your best interest.
Step 3:
If you disagree with our initial decision, you may notify Member Services in writing. Member Services will provide you with the option of either a written reconsideration, or an oral reconsideration. The term “reconsideration,” as used in this Step 3, applies to any issue other than those listed under the reconsideration step of the Medicare Appeals Process.