We are making a coverage decision for you each time we decide what is covered for you and how much we will pay:

• Usually, there is no problem. We decide the services or drugs that are covered and pay our share of the cost.
• In some cases we might decide the service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.

You can complete an exception request on our Member Portal (coming soon). You may also submit an exception utilizing the  Request for Medicare Prescription Drug Coverage Determination form.

If we respond no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal.

Who May File An Appeal, Grievance, or Coverage Determination?

You or someone you name to act for you (your authorized representative) may file an appeal, coverage determination, or grievance. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others already may be authorized under State law to act for you.

If you would want someone to act for you, you and your authorized representative must sign, date and send us a statement naming that person to act for you. To download a copy of the Appointment of Representation Form, please click the link below:

Appointment of Representation Form (Form CMS-1696)

Additional Questions?

For more information on coverage determinations, exceptions, appeals, and grievances please see the Chapter titled “What to do if you have a problem or complaint (coverage decisions, appeals, complaints)” in your 2012 Evidence of Coverage.

You can request an aggregate number of grievances, appeals, and exceptions that have been filed with our organization. Please see the contact information listed below.

If you have already asked for an appeal, coverage determination, or grievance, and would like a status update, the telephone number(s) are listed below.

Phone:	1-800-748-2544
TTY:	1-800-743-3333
Hours:	8 a.m.-5 p.m., Monday- Friday
Fax:	1-317-573-2841
Mailing:	ADVANTAGE Health Solutions 9045 River Road Suite 200 Indianapolis, IN 46240