Appeals

Appeals

Who can file an Appeal?

An appeal may be filed by any of the following:

  • You.
  • Your doctor.
  • Another health care provider or prescriber.
  • Someone else may file an appeal for you.If you would like, you can name another person to act for you as your “representative” to file an appeal on your behalf.
    • There may be someone who is already legally authorized to act as your representative under State law.
    • If you want a friend, relative, your doctor or other provider, or other person to be your representative, click here to obtain the “Appointment of Representative” form.The form gives that person permission to act on your behalf. It must be filled out and signed by you and by the person who you would like to act on your behalf.You must give us a copy of the signed form.
    • You may submit an equivalent written notice in lieu of the Appointment of Representative form:
      • Be in writing and signed and dated by you and your representative;
      • Provide a statement appointing the representative to act on your behalf;
      • A statement that the enrollee is authorizing the representative to act on his or her behalf for the issue, and a statement authorizing disclosure of individually identifying information to the representative;
      • Include a written explanation of the purpose and scope of the representation;
      • List your name and your representative's names, phone numbers, and addresses;
      • Include your Medicare Beneficiary Identifier or Mass Advantage ID number from your ID card;
      • Indicate your representative's professional status, if any, or relationship to you; and
      • Be filed with the entity processing your request.

When can an Appeal be filed?

You must make your appeal request within 60 calendar days from the date of the denial letter informing you of a denial or other adverse benefit determination. If you miss this deadline and have good cause, we may give you more time to appeal. You will need to provide a written explanation why your appeal is late so we can determine if there is good cause to process the untimely appeal. Examples of good cause for missing the deadline may include a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.

Where can an Appeal be filed?

To start your appeal, you (or your representative or your doctor or other provider/prescriber) must contact us.

Send us an expedited or standard appeal in writing:

Mass Advantage
P.O. Box 1285
Maryland Heights, MO 63043

Send appeals for Part D Prescription Drugs via email:MedDResponseTeam@magellanhealth.com

Send us a fax:

Appeals For Medical Care: 1-888-656-7783
Appeals for Part D Prescription Drugs: 1-888-904-1139

From October 1 to March 31, we're available 7 days a week from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we're available Monday through Friday from 8 a.m. to 8 p.m. EST.

Call us for expedited appeals only

H7670 Plan 001 and 002 (HMO): 1-844-918-0114, TTY: 711
H9904 Plan 001 (PPO): 1-844-915-0234, TTY: 711

From October 1 to March 31, we're available 7 days a week from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we're available Monday through Friday from 8 a.m. to 8 p.m. EST.

If you have questions or have an inquiry regarding the status of your appeal please contact Member Services at:

H7670 Plan 001 and 002 (HMO): 1-844-918-0114 TTY 711
H9904 Plan 001 (PPO): 1-844-915-0234, TTY: 711

From October 1 to March 31, we're available 7 days a week from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we're available Monday through Friday from 8 a.m. to 8 p.m. EST.

Review your Evidence of Coverage for additional details.

How to file an Appeal?

Your written request should include:

  • Your name, Member ID Number (found on your insurance card) address and phone number.We may contact you for additional information.
  • The items or services for which you’re requesting an appeal, the dates of service, and the reason(s) why you’re appealing.
  • If you’ve appointed a representative, include the name of the authorized representative and proof of representation.

Fast Decisions/Expedited Appeals

You have the right to request a quick response and receive expedited decisions affecting your medical treatment in cases where applying the standard timeline for a decision to be made could seriously jeopardize: 

    • your life or health, or
    • hurt your ability to function.

If you are asking for a “fast appeal”, you may make your appeal in writing or you may call us.

If your health plan or your doctor makes a request or supports your request that your health requires a “fast appeal,” we will automatically agree to give you a fast decision. Mass Advantage will issue a decision as fast as possible, but no later than seventy-two (72) hours for a medical item or service plus 14 calendar days.

If your request is for a Medicare Part D or Medicare Part B prescription drug, we will answer within seventy-two (72) hours.

If you ask for a fast decision on your own, without your doctor’s support, we will decide whether your health requires that we give you a fast decision.

    • If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter that says so (and we will use the standard deadlines instead).
    • This letter will tell you that if your doctor asks for the fast decision, we will automatically give a fast decision.
    • The letter will also tell how you can file a “fast complaint” about our decision to give you a standard decision instead of the fast coverage decision you requested.

Review the appeals process in your Evidence of Coverage document for more information.

From October 1 to March 31, we're available 7 days a week from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we're available Monday through Friday from 8 a.m. to 8 p.m. EST.

Standard Appeals

A standard appeal must be submitted in writing.

Mass Advantage will issue a decision as fast as possible, but no later than 30 calendar days after receiving a request for a medical item or service.

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to make a decision. If we need to take extra days, we will tell you in writing to explain the reasons for the extension and inform you of your right to file an expedited grievance if you disagree with the decision to extend the timeframe.

If your request is for a Medicare Part D or Medicare Part B prescription drug, we will answer within seven (7) calendar days after receiving the request.

If your request is for a Part D prescription drug payment redetermination we will answer within (14) calendar days after receiving the request.

If your request is for a payment reconsideration, we will answer within 60 calendar days after receiving the request.

Request Appeals and Grievance Data

You have a right to request Mass Advantage general data regarding the number and handling of appeals and grievances members have filed with the plan.Please contact Member Services at:

From October 1 to March 31, we're available 7 days a week from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we're available Monday through Friday from 8 a.m. to 8 p.m. EST.

For information on Appeals

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

You may also ask us for a coverage determination by phone at 844-918-0114 (HMO), or 844-915-0234 (PPO).

Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.

Enrollee's Information

Complete the following section ONLY if the person making this request is not the enrollee or prescriber:

Representation documentation for requests made by someone other than enrollee or the enrollee's prescriber:

Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact your plan or 1-800-Medicare.

Type of Coverage Determination Request

*NOTE: If you are asking for a formulary or tiering exception, your prescriber MUST provide a statement supporting your request. Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information. Your prescriber may use the attached “Supporting Information for an Exception Request or Prior Authorization” to support your request.

Important Note: Expedited Decisions

If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.

Use your mouse or finger to draw your signature above

Supporting Information for an Exception Request or Prior Authorization

FORMULARY and TIERING EXCEPTION requests cannot be processed without a prescriber's supporting statement. PRIOR AUTHORIZATION requests may require supporting information.

Prescriber's Information

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Diagnosis and Medical Information

DRUG HISTORY: (for treatment of the condition(s) requiring the requested drug)

DRUGS TRIED
(if quantity limit is an issue, list unit dose/total daily dose tried)
DATES of Drug TrialsRESULTS of previous drug trials FAILURE vs INTOLERANCE (explain)

 

Drug Safety

HIGH RISK MANAGEMENT OF DRUGS IN THE ELDERLY

OPIOIDS - (please complete the following questions if the requested drug is an opioid)

mg/day

RATIONALE FOR REQUEST