Appeals, Grievances, Coverage Determinations and Exceptions

As a member of MediGold, you have the right to request an appeal, file a grievance and ask for a coverage determination and a formulary exception. For status or process questions or to obtain an aggregate number of grievances, appeals and exceptions filed with the plan, please call Member Services at 1-800-240-3851 (TTY 711), 8 a.m. - 8 p.m., 7 days a week. You may also refer to your Evidence of Coverage for complete details.


Appeal

An appeal is a request you may make for reconsideration of our determination on a service, supply or drug you have received or requested. You may file an appeal when you believe that the services or supplies should be covered or that they should be covered differently than MediGold approved or paid them. Your doctor can also request an appeal for you.

Appeal For Medical Care

CALL

1-800-240-3851
8 a.m. - 8 p.m., 7 days a week

TTY

711
8 a.m. - 8 p.m., 7 days a week

FAX

614-546-3132

WRITE

MediGold
Attn: Appeals and Grievances Department
6150 East Broad Street, Suite EE320
Columbus, Ohio 43213-1574

Appeal for Part D Prescription Drugs

ONLINE

Request for Redetermination of Medicare Prescription Drug Denial – Use this form to request a Part D appeal online.

CALL

1-866-785-5714
24 hours a day, 7 days a week
Fast Appeals (an expedited process) 1-866-785-5714.

TTY

711
24 hours a day, 7 days a week

FAX

1-866-217-3353

WRITE

CVS Caremark Part D
Appeals Dept., MC109
P.O. Box 52000
Phoenix, AZ 85072-2000


Grievance

A grievance is a complaint that does not involve a coverage determination. For example, grievances may be filed if you are unhappy with the quality of care or service you receive from us or from our providers. You also have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug.

Grievances about Quality of Care (KEPRO)

CALL

1-855-408-8557

TTY

1-855-843-4776

Grievances about Medical Care

CALL

1-800-240-3851
8 a.m. - 8 p.m., 7 days a week

TTY

711
8 a.m. - 8 p.m., 7 days a week

FAX

614-546-3132

WRITE

MediGold
Attn: Appeals and Grievances Department
6150 East Broad Street, Suite EE320
Columbus, Ohio 43213-1574

Grievances about Part D prescription drugs

CALL

1-866-785-5714
24 hours a day, 7 days a week

TTY

711
24 hours a day, 7 days a week

FAX

1-866-217-3353

WRITE

MediGold
c/o CVS Caremark Part D Grievance Department
P.O. Box 53991, MC 121
Phoenix, AZ 85072-3991


Coverage Determination

A coverage determination is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can request an appeal. Your doctor can also request a coverage determination for you.

Coverage Determinations For Medical Care

CALL

1-800-240-3851
8 a.m. - 8 p.m., 7 days a week

Fast Decision, also known as expedited coverage determination, 1-800-240-3870

TTY

711
8 a.m. - 8 p.m., 7 days a week

FAX

614-546-3132

Fast Decision, also known as expedited coverage determination, 614-546-3135

WRITE

MediGold
Attn: Medical Management
6150 East Broad Street, Suite EE320
Columbus, Ohio 43213-1574

Coverage Determinations for Part D Prescription Drugs

ONLINE

Request for Medicare Prescription Drug Coverage Determination – Use this form to request a Part D coverage decision online.

CALL

1-866-785-5714
24 hours a day, 7 days a week

TTY

711
24 hours a day, 7 days a week

FAX

1-866-239-8303

WRITE

CVS Caremark Part D
Appeals Dept., MC109
P.O. Box 52000
Phoenix, AZ 85072-2000


Formulary Exception

You may ask us for a formulary exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to utilization management restrictions, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision.

Formulary Exceptions for Part D Prescription Drugs

ONLINE

Request for Medicare Prescription Drug Formulary Exception – Use this form to request a Part D formulary exception.

CALL

1-866-785-5714
24 hours a day, 7 days a week

TTY

711
24 hours a day, 7 days a week


Appoint a Representative

To appoint a representative to act on your behalf, you may download this form or call Member Services for assistance.

CMS Appointment of Representative Form (By clicking the link, you will be leaving the MediGold website.)

You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision.


File a Complaint with Medicare

You can also submit a complaint about your Medicare health plan or prescription drug plan directly to Medicare using the Medicare Complaint Form (by clicking the link, you will be leaving the MediGold website) or you may call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Updated 10/2015