You have the right to appeal if you do not agree with Network Health's decision(s) about your health care. You must file your appeal in writing or orally within 60 calendar days after the date of the denial. If you cannot make this deadline due to an unforeseen circumstance that is acceptable to Network Health, an extension can be allotted.
You have the right to appeal if you believe the following.
You or someone you have named to act on your behalf (called your representative) may file an appeal. You can identify a relative, friend, advocate, attorney, doctor or an authorized person identified by applicable State law.
To learn how to identify someone to act on your behalf, you may call us at 800-378-5234 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 8 p.m. During October 1–March 31 of each year, we’re staffed Monday–Sunday 8 a.m. to 8 p.m.
You and the person you have identified to act on your behalf must sign, date and send us a statement clearly identifying your name, the identified person's name you would like to act on your behalf with dates and signature from both parties to the following.
Fax 920-720-1832 or mail your request to
To file an appeal, you may call us at 800-378-5234 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 8 p.m. During October 1–March 31 of each year, we’re staffed Monday–Sunday 8 a.m. to 8 p.m., or you can send it to us in writing via faxing to 920-720-1832. You may also mail your appeal to
If your request is for medical coverage or services that you haven’t received yet, you can request a standard appeal. We will supply you a decision no later than 30 days after we receive your appeal request. (We may extend this time by up to 14 days if you request an extension, or if we need additional information and the extension benefits you.)
You can request a fast appeal on services that you haven’t received yet if you or your doctor believe that your health could be seriously harmed by waiting too long for a decision. We will supply you a decision on a fast appeal no later than 72 hours after we receive your appeal request. (We may extend this time by up to 14 days if you request an extension, or if we need additional information and the extension benefits you.)
Examples of a fast appeal would be the following.
If a doctor requests a fast appeal for you, or supports you in your request for one, the doctor shall indicate in writing that waiting for 30 days could seriously harm your health.
If you request a fast appeal without support from a doctor, we will review and make a determination if your health requires a fast appeal. If the review and determination supports not approving a fast appeal, we will review and make a determination on your appeal within 30 days and notify you within the applicable timeline.
If our decision is not favorable to your expectations, we will automatically forward your appeal request to the CMS contractor (MAXIMUS Federal Services) to initiate an independent review. MAXIMUS will send you a letter with their decision within three working days of receipt of your case from Network Health.
If your request is for payment of services you have already received, you can request a standard appeal. We must supply you with a decision no later than 60 days after we receive your appeal.
You are not required to submit additional information to support your request for services or payment for services already received. Network Health Insurance Corporation is responsible for gathering all necessary medical information, however, it may be helpful to you to include additional information to clarify or support your position.
For example, you may want to include in your appeal request information such as medical records or physician opinions in support of your appeal. To obtain medical records, send a written request to your Primary Care Physician. If your medical records from specialist physicians are not included in your medical record from your Primary Care Physician, you may need to make a separate written request to the specialist physician(s) who provided medical services to you.
Upon submission of your request for appeal to Network Health, we will complete a full and fair review to determine if our original denial of the requested services or payment for services can be modified. After we complete our review, we will notify you of our decision. If our decision is not in your favor, we will automatically forward your appeal request to the CMS Contractor (MAXIMUS Federal Services) for a full independent review. This service is provided by Medicare for a new and impartial review of your case outside of your Medicare Advantage organization. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights upon an unfavorable review finding.
If you’re dissatisfied with the service or quality provided by your plan or doctor, we’re here to work with you through any issues. You have the right to file a grievance (a formal complaint) about how Network Health, our vendors or contracted providers provided services.
Examples of situations appropriate for a grievance include the following.
If you have a grievance, we encourage you to first call the member experience team at the number listed in your Evidence of Coverage. We will try and resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you.
You can submit a grievance over the phone or in writing within 60 calendar days from the date of the event. You may call us at 800-378-5234 (TTY 800-947-3529), Monday–Friday from 8 a.m. to 8 p.m. During October 1–March 31 of each year, we’re staffed Monday–Sunday 8 a.m. to 8 p.m. or, you can send it to us in writing via faxing to 920-720-1832. You may also mail your appeal to
We will complete an investigation of your grievance as quickly as your case requires and send you a letter about this no later than 30 calendar days from the date we received your request. If we need more time to investigate the situation, we will inform you about that extension prior to the end of the initial 30-day period.
Whenever you ask for a Part D prescription drug benefit coverage determination, the first step is called “requesting a coverage determination.” When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. You must contact Express Scripts, Inc. at 800-316-3107 (TTY 800-899-2114), 24 hours a day seven days a week, if you would like to request a coverage determination. You cannot request an appeal if we have not issued a coverage determination.
There are two types of coverage determinations; standard or fast. A decision about whether we will cover a Part D prescription drug can be a standard coverage determination. This is made within the standard time frame of 72 hours. You can only request a fast decision if you or your doctor believes that waiting for a standard decision could seriously harm your health or your ability to function. Fast decisions apply only to requests for Part D drugs that you have not received yet. For a fast decision, we will give you our decision within 24 hours or sooner if your health requires.
You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make, such as:
If you request an exception, your physician must provide a statement to support your request. Generally, we will only approve your request for an exception if the alternative drugs included in the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition, and you are still enrolled in Network Health’s Medicare Advantage Plan. If we deny your exception request you can appeal our decision.
If you are unhappy with the coverage determination, you can ask for an appeal. You may also appeal our decision for the reasons listed below.
You must send your appeal to Network Health in writing within 60 calendar days after the date of the denial. We can give you more time if you have a good reason for missing the deadline, such as being in the hospital.
If your request is about reimbursement for a Part D drug you already paid for and received you can ask for a standard appeal. We must give you a decision no later than fourteen (14) calendar days from the date we receive the appeal. If your request is about a part D drug that has been denied you can ask for a standard appeal. We must give you a decision no later than seven (7) calendar days from the date we receive your appeal. We will make a decision sooner if your health condition requires us to. If we do not give you our decision within the fourteen calendar days for reimbursement for a Part D drug you already paid for and received or within seven calendar days for a part D drug that has been denied your request will automatically go to the second level of appeal where an independent organization will review your case.
You can make a request for a fast appeal if you or your doctor believe that your health could be seriously harmed by waiting too long for a decision. We must decide on a fast appeal no later than 72 hours after we receive your appeal but will make it sooner if your health requires us to. If we do not give you our decision within 72 hours, your request will automatically go to the second level of appeal, where an independent organization will review your case.
If any doctor asks for a fast appeal for you, or supports you in asking for one, and the doctor indicates that waiting for seven calendar days could seriously harm your health, we will automatically give you a fast appeal. If you ask for a fast appeal without support from a doctor, we will decide if your health requires a fast appeal. If we do not give you a fast appeal, we will decide your appeal within seven calendar days.
If we deny any part of your appeal, you or your representative have the right to ask for an independent review organization to review your case. This independent review organization contracts with the federal government and is not part of Network Health Insurance Corporation Medicare Advantage pharmacy plans. You must make your 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. You must send your written request to the independent review organization whose name and address is included in the level 1 redetermination.
A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have a problem with Network Health Insurance Corporation’s Medicare Advantage pharmacy plans or one of our network pharmacies that relates to coverage for a prescription drug.
For example, you would file a grievance if you have a problem with things such as:
If you have a grievance, we encourage you to first call the member experience team at the number listed in your Evidence of Coverage. We will try and resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you.
You can submit a grievance over the phone or in writing within 60 calendar days from the date of the event. You may call us at 800-378-5234 (TTY 800-947-3529), Monday–Friday from 8 a.m. to 8 p.m. During October 1–March 31 of each year, we’re staffed Monday–Sunday, 8 a.m. to 8 p.m. You may also mail your appeal to
This document provides summary details about your appeal and grievance rights. You will obtain the full procedures when you enroll in Network Health’s Medicare Advantage Plan.
If you have questions about the appeal or grievance process, you may call us at 800-378-5234 (TTY 800-947-3529), Monday–Friday from 8 a.m. to 8 p.m. During October 1–March 31 of each year, we’re staffed Monday–Sunday, 8 a.m. to 8 p.m. or you can send it to us in writing via fax to 920-720-1832. You may also mail your appeal to
You can contact Medicare for more information about benefits and services, including general information about Medicare Advantage Prescription Drug coverage.
Telephone
1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week
If you are hearing or speech impaired, please call 1-877-486-2048.
Online
www.medicare.gov
The Medicare website for the Office of the Medicare Ombudsman (OMO) can help you with complaints, grievances and information requests.