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What is a grievance?
What types of problems might lead to you filing a grievance?
Who may file a grievance
Filing a grievance with UPREHS
Fast Grievances
For quality of care problems, you may also complain to the QIO
Complaints and Appeals about your Part D Prescription Drugs
Introduction
PART 1. Requests for Part D drugs
Initial Determinations
What is an exception?
What is an exception?
Who may ask for an initial determination?
Asking for a standard or fast initial determination
Asking for a standard decision
Asking for a fast decision
What happens when you request an initial determination?
What happens if we decide completely in your favor?
What happens if we decide against you?
APPEAL LEVEL 1:
Appeal to UPREHS
Who may file your appeal of the initial determination?
How soon must you file your appeal?
How to file your appeal
Getting information to support your appeal
How soon must we decide on your appeal?
What happens if we decide completely in your favor?
APPEAL LEVEL 2: Independent Review Entity (IRE)
How to file your appeal
How soon must the IRE decide?
If the IRE decides completely in your favor:
APPEAL LEVEL 3:
Administrative Law Judge (ALJ)
How to file your appeal
How soon will the Judge make a decision?
If the Judge decides in your favor:
APPEAL LEVEL 4: Medicare Appeals Council (MAC)
How to file your appeal
How soon will the Council make a decision?
If the Council decides in your favor:
APPEAL LEVEL 5: Federal Court
How to file your appeal
How soon will the Judge make a decision?
If the Judge decides in your favor:
If the Judge decides against you:
Favorable Decisions by the ALJ, MAC, or a Federal Court Judge
Grievance, Exceptions & Appeals Forms
What is a Grievance?
A grievance is any complaint, other than one that involves a request for an initial determination or an
appeal as described in Section 7 of this manual. Grievances do not involve problems related to
approving or paying for Part D drugs.
We encourage you to let us know right away if you have questions, concerns, or problems related to
your prescription drug coverage. Please call our Customer Services at 1-800-547-0421 and we will help
you with any questions or concerns. If we will not pay for or give you the Part D drugs you want, you
must follow the rules outlined in this section for appeals. If you have one of the below types of problems
and want to make a complaint, it is called “filing a grievance.”
What types of problems might lead to you filing a grievance?
- You feel that you are being encouraged to leave (disenroll from) our Plan.
- Problems with the customer service you receive.
- Waiting too long to have prescriptions filled.
- Rude behavior by pharmacists or other staff.
- If you disagree with our decision not to give you a fast decision or appeal.
- You believe our notices and other written materials are difficult to understand.
- We don’t give you a decision within the required timeframe.
- We don’t forward your case to the independent review entity if we do not give you a decision
on time.
- We don’t give you required notices.
Who may file a grievance
You or someone you name may file a grievance. The person you name would be your “representative.”
You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons
may already be authorized by the Court or in accordance with State law to act for you. If you want
someone to act for you who is not already authorized by the Court or under State law, then you and that
person must sign and date a statement that gives the person legal permission to be your representative.
To name your representative, you may call Customer Services at 1-800-547-0421 or complete the
Appointment of Representative form in the front of this book and submit it to UPREHS.
Filing a grievance with UPREHS
If you have a complaint, you or your representative may call UPREHS Customer Services
at 1-800-547-0421.
- If you have a grievance, please call Customer Services at 1-800-547-0421 first. We will try to
resolve any complaint that you might have quickly over the phone. If you request a written
response to your phone complaint, we will respond in writing to you. If we cannot resolve your
complaint over the phone, we have a formal procedure to review your complaints.
- We must notify you of our decision about your grievance as quickly as your case requires based
on your health status, but no later than 30 calendar days after receiving your complaint. We may
extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a
need for additional information and the delay is in your best interest.
Fast Grievances
In certain cases, you have the right to ask for a “fast grievance” meaning we will answer your grievance
within 24 hours. We discuss situations where you may request a fast grievance further in this section.
For quality of care problems, you may also complain to the QIO
You may complain about the quality of care received under Medicare. You may complain to us using
the grievance process, to the Quality Improvement Organization (QIO) in your state, or both. If you file
with the QIO, we must help them resolve the complaint. See the Introduction section of this book for
help to find the QIO in your state.
Complaints and Appeals about your Part D Prescription Drugs
This section explains how you ask for coverage of your Part D drug(s) or payments in different
situations. These types of requests and complaints are discussed below in Part 1.
Other complaints that do not involve the types of requests or complaints discussed below in Part 1 are
considered grievances. You would file a grievance if you have any type of problem with us, or one of
our network providers that does not relate to coverage for Part D drugs. For more information about
grievances, see Section 6.
PART 1. Requests for Part D drugs
This part explains what you can do if you have problems getting the Part D drugs you request, or
payment (including the amount you paid) for a Part D drug you already received.
If you have problems getting the Part D drugs you need, or payment for a Part D drug you already
received, you must request an initial determination with the plan.
Initial Determinations
The initial determination we make is the starting point for dealing with requests you may have about
covering a Part D drug you need, or paying for a Part D drug you already received. Initial decisions
about Part D drugs are called coverage determinations. With this decision, we explain whether we will
provide the Part D drug you are requesting, or pay for the Part D drug you already received.
The following are examples of requests for initial determinations:
- The following are examples of requests for initial determinations:
- You ask for an exception to our utilization management tools - such as requesting additional
drugs that have a Quantity Limit.
- You ask for a Tier 3 non-preferred Part D drug at the preferred cost-sharing level of Tier 2. This
is a request for a tiering exception. See "What is an exception?" below for more information
about the exceptions process.
- You ask us to pay you back for the cost of a drug you bought at an out-of-network pharmacy. In
certain circumstances, out-of-network purchases, including drugs provided to you in a
physician’s office will be covered UPREHS. See Filling Prescriptions Outside of Network in
Section 2 for a description of these circumstances.
What is an exception?
An exception is a type of initial determination (also called a coverage determination”) involving a Part D
drug. You or your doctor may ask us to make an exception to our Part D coverage rules in a number of
situations.
- All Medicare Part D drugs are included in the UPREHS formulary, therefore, there are no
exceptions to the UPREHS formulary.
- Excluded drugs cannot be covered by Medicare Part D. UPREHS does covers some drugs that
are not covered by Medicare. Medicare Part D will not make an exception to excluded drugs.
- You may ask us to waive coverage restrictions or limits on your Part D drug. For example, for
certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has
a quantity limit, you may ask us to waive the limit and cover more.
- You may ask us to provide a higher level of coverage for your Part D drug. If your Part D drug is
contained in our Tier 3, you may ask us to cover it at the cost-sharing amount that applies to
drugs in Tier 2. This would lower the copayment amount you must pay for your Part D drug.
- You may not ask for an exception to drugs that are in Tier 1, 2 or 4.
We will only approve your request for an exception if the alternative preferred Part D drugs included in
Tiers 1, 2, or 4 would not be as effective in treating your condition and/or would cause you to have
adverse medical effects.
Your doctor must submit a statement supporting your exception request. In order to help us make a
decision more quickly, the supporting medical information from your doctor should be sent to us with
the exception request.
If we approve your exception request, our approval is valid for the remainder of the calendar year, so
long as your doctor continues to prescribe the Part D drug for you and it continues to be safe for treating
your condition. If we deny your exception request, you may appeal our decision.
You may call Customer Services at 1-800-547-0421 to ask for any of these requests.
Who may ask for an initial determination?
You, your prescribing physician, or someone you name may ask us for an initial determination. The
person you name would be your appointed representative. You may name a relative, friend, advocate,
doctor, or anyone else to act for you. Other persons may already be authorized under State law to act for
you. If you want someone to act for you who is not already authorized under State law, then you and that
person must sign and date a statement that gives the person legal permission to be your appointed
representative. If you are requesting Part D drugs, this statement must be sent to us at the address or fax
number listed on the cover of this book. To learn how to name your appointed representative, you may
call Customer Services or use the Appointment of Representative form in the front of this book.
You also have the right to have a lawyer 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.
Asking for a standard or fast initial determination
A decision about whether we will give you, or pay for, the Part D drug you are requesting can be a
standard decision that is made within the standard time frame, or it can be a fast decision that is made
more quickly. A fast decision is also called an expedited decision.
Asking for a standard decision
To ask for a standard decision for a Part D drug you, your doctor, or your representative should call, fax,
or write us at the numbers or address listed on the cover of this book.
Asking for a fast decision
You may ask for a fast decision only if you or your doctor believe that waiting for a standard decision
could seriously harm your health or your ability to function. (Fast decisions apply only to requests for
benefits that you have not yet received. You cannot get a fast decision if you are asking us to pay you
back for a benefit that you already received.)
If you are requesting a Part D drug that you have not yet received, you, your doctor, or your
representative may ask us to give you a fast decision by calling, faxing, or writing us at the numbers on
the cover of this book.
Be sure to ask for a fast or expedited decision. If your doctor asks for a fast decision for you, or supports
you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm
your health or your ability to function, we will automatically give you a fast decision.
If you ask for a fast decision without support from a doctor, we will decide if your health requires 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 informing you that if you get a doctor’s support for a fast review, we will
automatically give you a fast decision. The letter will also tell you how to file a fast grievance. You have
the right to file a fast grievance if you disagree with our decision to deny your request for a fast review
(for more information about fast grievances, see 5). If we deny your request for a fast initial
determination, we will give you a standard decision.
What happens when you request an initial determination?
- For a standard initial determination about a Part D drug (including a request to pay you back for
a Part D drug that you have already received).
- Generally, we must give you our decision no later than 72 hours after we receive your request,
but we will make it sooner if your request is for a Part D drug that you have not received yet
and your health condition requires us to. However, if your request involves a request for a
tiering exception, or an exception from utilization management rules – such as quantity limits,
we must give you our decision no later than 72 hours after we receive your physician's
supporting statement explaining why the drug you are asking for is medically necessary.
- If you have not received an answer from us within 72 hours after we receive your request
(or your physician's supporting statement if your request involves an exception), your
request will automatically go to Appeal Level 2.
- For a fast initial determination about a Part D drug that you have not yet received.
- If we give you a fast review, we will give you our decision within 24 hours after you or
your doctor ask for a fast review. We will give you the decision sooner if your health
condition requires us to. If your request involves a request for an exception, we will give
you our decision no later than 24 hours after we have received your physician's supporting
statement, which explains why the drug you are asking for is medically necessary.
- If we decide you are eligible for a fast review and you have not received an answer from us
within 24 hours after receiving your request (or your physician's supporting statement if
your request involves an exception), your request will automatically go to Appeal Level 2.
What happens if we decide completely in your favor?
- For a standard decision about a Part D drug (including a request to pay you back for a Part D drug that you have already received).
- We must cover the Part D drug you requested as quickly as your health requires, but no
later than 72 hours after we receive the request. If your request involves a request for an
exception, we must cover the Part D drug you requested no later than 72 hours after we
receive your physician's supporting statement. If you are asking us to pay you back for a
Part D drug that you already paid for and received, we must send payment to you no later
than 30 calendar days after we receive the request (or supporting statement if your request
involves an exception).
- For a fast decision about a Part D drug that you have not yet received
- We must cover the Part D drug you requested no later than 24 hours after we receive your
request. If your request involves a request for an exception, we must cover the Part D drug
you requested no later than 24 hours after we receive your physician's supporting
statement.
What happens if we decide against you?
If we decide against you, we will send you a written decision explaining why we denied your request. If an initial determination does not give you all that you requested, you have the right to appeal the decision. (See Appeal Level 1.)
Appeal Level 1: Appeal to UPREHS
You may ask us to review our initial determination, even if only part of our decision is not what you
requested. An appeal to the plan about a Part D drug is also called a plan redetermination. When we
receive your request to review the initial determination, we give the request to people at our organization
who were not involved in making the initial determination. This helps ensure that we will give your
request a fresh look.
Who may file your appeal of the initial determination?
If you are appealing an initial decision about a Part D drug, you or your representative may file a standard appeal request, or you, your representative, or your doctor may file a fast appeal request. Please see "Who may ask for an initial determination?" for information about appointing a representative.
How soon must you file your appeal?
You must file the appeal request within 60 calendar days from the date included on the notice of our
initial determination. We may give you more time if you have a good reason for missing the deadline.br />
How to file your appeal
- Asking for a standard appeal
To ask for a standard appeal about a Part D drug a signed, written appeal request must be faxed to the number or sent to the address listed on the cover of this book.
- Asking for a fast appeal
If you are appealing a decision we made about giving you a Part D drug that you have not
received yet, you and/or your doctor will need to decide if you need a fast appeal. The rules
about asking for a fast appeal are the same as the rules about asking for a fast initial
determination. You, your doctor, or your representative may ask us for a fast appeal by calling,
faxing, or writing us at the numbers or address listed on the cover of this book.
Be sure to ask for a fast or expedited review. Remember, if your doctor provides a written or oral
supporting statement explaining that you need the fast appeal, we will automatically give you a
fast appeal. If you ask for a fast decision without support from a doctor, we will decide if your
health requires 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 informing you that if you get a doctor’s
support for a fast review, we will automatically give you a fast decision. The letter will also tell
you how to file a fast grievance. You have the right to file a fast grievance if you disagree with
our decision to deny your request for a fast review (for more information about fast grievances,
see Section 5. If we deny your request for a fast appeal, we will give you a standard appeal.
Getting information to support your appeal
We must gather all the information we need to make a decision about your appeal. If we need your
assistance in gathering this information, we will contact you or your representative. You have the right
to obtain and include additional information as part of your appeal. For example, you may already have
documents related to your request, or you may want to get your doctor’s records or opinion to help
support your request. You may need to give the doctor a written request to get information.
You may give us your additional information to support your appeal by calling, faxing, or writing us at
the numbers or address listed on the cover of this book. You may also deliver additional information in
person to UPREHS at 1040 North 2200 West Suite 200, Salt Lake City, Utah 84116.
You also have the right to ask us for a copy of information regarding your appeal. You may call or write
us at the phone number or address listed on the cover of this book.
How soon must we decide on your appeal?
- For a standard decision about a Part D drug that includes a request to pay you back for a Part D drug you have already paid for and received.
- We will give you our decision within seven calendar days of receiving the appeal request.
We will give you the decision sooner if you have not received the drug yet and your health
condition requires us to. If we do not give you our decision within seven calendar days,
your request will automatically go to Appeal Level 2.
- For a fast decision about a Part D drug that you have not yet received.
- We will give you our decision within 72 hours after we receive the appeal request. We will
give you the decision sooner if your health condition requires us to. If we do not give you
our decision within 72 hours, your request will automatically go to Appeal Level 2.
What happens if we decide completely in your favor?
- For a standard decision about a Part D drug (including a request to pay you back for a Part D
drug that you have already received).
- We must cover the Part D drug you requested as quickly as your health requires, but no
later than 7 calendar days after we receive the request. If you are asking us to pay you back
for a Part D drug that you already paid for and received, we must send payment to you no
later than 30 calendar days after we receive the request.
- For a fast decision about a Part D drug that you have not yet received.
- We must cover the Part D drug you requested no later than 72 hours after we receive your request.
Appeal Level 2: Independent Review Entity (IRE)
At the second level of appeal, your appeal is reviewed by an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this entity.
How to file your appeal
If you asked for Part D drugs or payment for Part D drugs and we did not rule completely in your favor
at Appeal Level 1, you may file an appeal with the IRE. If you choose to appeal, you must send the
appeal request to the IRE. The decision you receive from the plan (Appeal Level 1) will tell you how to
file this appeal, including who can file the appeal and how soon it must be filed.
How soon must the IRE decide?
The IRE has the same amount of time to make its decision as the plan had at Appeal Level 1.
If the IRE decides completely in your favor:
The IRE will tell you in writing about its decision and the reasons for it.
- For a decision to pay you back for a Part D drug you already paid for and received, we must send payment to you within 30 calendar days from the date we receive notice reversing our decision.
- For a standard decision about a Part D drug you have not yet received, we must cover the Part D drug you asked for within 72 hours after we receive notice reversing our decision.
- For a fast decision about a Part D drug you have not yet received, we must cover the Part D drug you asked for within 24 hours after we receive notice reversing our decision.
Appeal Level 3: Administrative Law Judge (ALJ)
If the IRE does not rule completely in your favor, you or your representative may ask for a review by an
Administrative Law Judge (ALJ) if the dollar value of the Part D drug you asked for meets the minimum
requirement provided in the IRE’s decision. During the ALJ review, you may present evidence, review
the record (by either receiving a copy of the file or accessing the file in person when feasible), and be
represented by counsel.
How to file your appeal
The request must be filed with an ALJ within 60 calendar days of the date you were notified of the
decision made by the IRE (Appeal Level 2). The ALJ may give you more time if you have a good
reason for missing the deadline. The decision you receive from the IRE will tell you how to file this
appeal, including who can file it.
The ALJ will not review your appeal if the dollar value of the requested Part D drug does not meet the
minimum requirement specified in the IRE's decision. If the dollar value is less than the minimum
requirement, you may not appeal any further.
How soon will the Judge make a decision?
The ALJ will hear your case, weigh all of the evidence, and make a decision as soon as possible.
If the Judge decides in your favor:
See the section Favorable Decisions by the ALJ, MAC, or a Federal Court Judge below for
information about what we must do if our decision denying what you asked for is reversed by an ALJ.
Appeal Level 4: Medicare Appeals Council (MAC)
If the ALJ does not rule completely in your favor, you or your representative may ask for a review by
the Medicare Appeals Council (MAC).
How to file your appeal
The request must be filed with the MAC within 60 calendar days of the date you were notified of the
decision made by the ALJ (Appeal Level 3). The MAC may give you more time if you have a good
reason for missing the deadline. The decision you receive from the ALJ will tell you how to file this
appeal, including who can file it.
How soon will the Council make a decision?
The MAC will first decide whether to review your case (it does not review every case it receives). If the
MAC reviews your case, it will make a decision as soon as possible. If it decides not to review your
case, you may request a review by a Federal Court Judge (see Appeal Level 5). The MAC will issue a
written notice explaining any decision it makes. The notice will tell you how to request a review by a
Federal Court Judge.
If the Council decides in your favor:
See the section Favorable Decisions by the ALJ, MAC, or a Federal Court Judge below for information about what we must do if the MAC reverses our decision denying what you asked for.
Appeal Level 5: Federal Court
You have the right to continue your appeal by asking a Federal Court Judge to review your case if the
amount involved meets the minimum requirement specified in the Medicare Appeals Council's decision,
you received a decision from the Medicare Appeals Council (Appeal Level 4), and:
- The decision is not completely favorable to you, or
- The decision tells you that the MAC decided not to review your appeal request.
How to file your appeal
In order to request judicial review of your case, you must file a civil action in a United States district
court within 60 calendar days after the date you were notified of the decision made by the Medicare
Appeals Council (Appeal Level 4). The letter you get from the Medicare Appeals Council will tell you
how to request this review, including who can file the appeal.
A Federal Court will not review your appeal request if the dollar value of the requested Part D drug does not meet the minimum requirement specified in the MAC’s decision.
How soon will the Judge make a decision?
The Federal Court Judge will first decide whether to review your case. If it reviews your case, a decision
will be made according to the rules established by the Federal judiciary.
If the Judge decides in your favor:
See the section Favorable Decisions by the ALJ, MAC, or a Federal Court Judge below for information about what we must do if a Federal Court Judge reverses our decision denying what you asked for.
If the Judge decides against you:
You may have further appeal rights in the Federal Courts. Please refer to the Judge’s decision for further
information about your appeal rights.
Favorable Decisions by the ALJ, MAC, or a Federal Court Judge
This section explains what we must do if our initial decision denying what you asked for is reversed by
the ALJ, MAC, or a Federal Court Judge.
- For a decision to pay you back for a Part D drug you already paid for and received, we must send payment to you within 30 calendar days from the date we receive notice reversing our decision.
- For a standard decision about a Part D drug you have not yet received, we must cover the Part D drug you asked for within 72 hours after we receive notice reversing our decision.
- For a fast decision about a Part D drug you have not yet received, we must cover the Part D drug you asked for within 24 hours after we receive notice reversing our decision.
Appointment of Representative
Your Appeal Rights
Appeals & Grievances Instructions
| Last Updated: 4/13/2010 |
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UPREHS. Plan for Life.™ 
