Grievances, Coverage Determination, Appeals and Reimbursement

 

Below you will find procedural information on how to file a grievance, coverage determination, and an appeal for Part C and Part D inquiries.

Should you need to file a complaint with Medicare you may do so by clicking on the link below instead of filing your complaint telephonically at 1-800-Medicare.
Complaints can be filed via CMS using this link

Information on how to obtain aggregate numbers of Grievances, Coverage Determinations, Appeals and Exceptions

As a Medicare Advantage Organization, HealthSun Health Plans must disclose grievances, coverage determinations, appeals and exceptions data, upon request, to individuals eligible to elect a Medicare Advantage organization. By appeals data we mean all appeals filed with HealthSun Health Plans that are accepted for review, or withdrawn upon the member’s request, but excludes appeals that HealthSun Health Plans forwards to CMS’ Independent Review Entity (IRE) for dismissal.

Call our Member Services Department if you have any questions Toll Free at 1-877-336-2069 or 305-447-4458. Our fax number is 305-234-9275 and you can find our mailing address at the end of this page.

 

Appointment of Representative (AOR)

CMS Appointment of Representation Form

Medicare allows a beneficiary to appoint any individual (such as a relative, friend, advocate, physician, or an attorney) to act on his or her behalf as a representative in the grievances, coverage decisions and/or appeals process. The beneficiary making the appointment and the representative accepting the appointment must sign, date, and complete the Appointment of Representative Form. The appointment is valid for one year from the date the form is signed.

Due in part to the incapacitated or legally incompetent status of a member, a representative is not required to produce a representative form. Instead, he or she must produce other appropriate legal papers supporting his or her status as the authorized representative.

 

Procedural Information

How to file a Grievance

Grievances/Appeal Form

The Grievance/Appeal Form is not required

You can file a grievance in one of two ways: verbally or in writing. You can call us and state your complaint to one of our Member Service Representatives. You can mail or fax your complaint in writing to our main office. You or your appointed representative may file a grievance.

Call our Member Services Department if you have any questions Toll Free at 1-877-336-2069 or 305-447-4458. Our fax number is 305-234-9275 and you can find our mailing address at the end of this page.

We will provide you with our resolution in writing within the designated timeframe from the date we receive your grievance. The grievance process generally takes up to 30 days to provide you with our written response. In some instances, it can take 14 more days if you ask for more time or if we need additional information that may benefit you, in which we will notify you in writing.

You can make complaints about quality of care to the Quality Improvement Organization (QIO) instead of filing your complaint with the plan or you may file your complaint to the QIO and to our plan. If you file a complaint with the QIO we will work together with them to resolve your complaint. To obtain information to the QIO contact our Member Services Department at the number provided at the end of this page.

 

How to Request Coverage Determination or an Organizational Determination

Medicare Part D Coverage Determination Request Form
B vs. D Coverage Determination Request Form
CMS Model Medicare Prescription Drug Coverage Determination Request Form 

The Part D Coverage Determination Request Forms provided here are not required.

You can request for a determination of coverage for your prescription drugs and medical services in one of two ways: verbally or in writing. You can call us and make your request to one of our Member Service Representatives or you can send your request in writing to our main office by fax or mail. If you want to a coverage determination for a prescription drug you can fax your written request directly to our Part D Department at 305-643-4323 or e-mail partdservices@healthsun.com. You, your physician, or your appointed representative can request the type of coverage decision that you need.

Call our Member Services Department if you have any questions Toll Free at 1-877-336-2069 or 305-447-4458. Our fax number is 305-234-9275 and you can find our mailing address at the end of this page.

We will provide you with our decision in writing within the designated timeframe from the date we receive your request. The timeframe depends on the type of request. In some instances, we can take 14 more days if you ask for more time or if we need additional information that may benefit you, in which we will notify you in writing.

This table shows you the timeframe of when you can expect our decision on your request for medical care and prescription drug coverage determination.

 

Decisions for your Medical Care Coverage

Decisions for your Prescription Drug Coverage

Standard Decision 14 Days 72 Hours
Fast Decision 72 Hours 24 Hours

 

IMPORTANT: If your health requires a quick response, you should ask the plan to make a fast decision. To get a fast decision, you must ask for it and the plan will decide if your health requires a Fast Decision. To qualify, you must be asking for coverage on medical care or a drug that you have not yet received. You must also indicate that the standard timeframe could cause serious harm to your health or impair your ability to function. If your physician tells us that your health requires a Fast Decision, the plan will automatically agree to give you a Fast Decision.

 

How to request an Appeal

Grievance/Appeal Form
Redetermination of Medicare Prescription Drug Denial Request Form

The Appeals or Redetermination Forms are not required.

If you disagree with the coverage decision that the plan has made on your medical care service or prescription drug, you can appeal the decision in writing. You can mail or fax your appeal request in writing to our main office. The appeal request must be signed by you or your appointed representative

Call our Member Services Department if you have any questions Toll Free at 1-877-336-2069 or 305-447-4458. Our fax number is 305-234-9275 and you can find our mailing address at the end of this page.

We will provide you with our decision in writing within the designated timeframe from the date we receive your appeal request. The timeframe depends on the type of request. In some instances, we can take 14 more days if you ask for more time or if we need additional information that may benefit you, in which we will notify you in writing.

This table shows you the timeframe of when you can expect our decision on your appeal for coverage.

 

Decisions for your Medical Coverage

Decisions for your Prescription Drugs Coverage

Standard Decision for Denial of Payment 60 Days 7 Days
Standard Decision for Denial of Service 30 Days 7 Days
Expedited Decision for Denial of Service 72 Hours 72 Hours

 

How do I request an exception to the HealthSun Drug Formulary?

You can ask HealthSun to make the following exceptions to our Prescription Drug coverage rules:

  • Cover a drug that is not on our Formulary. If approved, it will be covered at a pre-determined cost-sharing level and will not be allowed to a lower cost-sharing level.
  • Cover a Formulary drug at a lower cost-sharing level if it is not on the specialty tier. If approved, this would lower the cost of your drug.
  • Waive coverage restrictions or limits on your drug. For example, for certain drugs, HealthSun limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, HealthSun will only approve your request for an exception if the alternative drug is included on our Formulary.  The lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact our Member Services Department to ask us for an initial coverage decision for an exception on the Formulary, tiers or a utilization restriction. You should also submit a statement from your prescriber or physician supporting your request.  Generally, we must make our decision within 72 hours of getting your prescriber's supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

 

How to request Reimbursement or Payment for a service or bill you have received

Reimbursement Request Form
Part D Reimbursement Request Form

The Reimbursement Forms are not required.

You can request that we pay you back for a service that you have received. You can also request that we pay an outstanding bill that you have received. You can mail your request for payment along with the bill or your receipts and any other documentation of payment you have made. It is a good idea to make a copy of your documents for your records. You can use our Reimbursement Request Form to help us process the information faster. You or your appointed representative can request reimbursement and/or payment.

Call our Member Services Department if you have any questions Toll Free at 1-877-336-2069 or 305-447-4458. Our fax number is 305-234-9275 and you can find our mailing address at the end of this page.

You must submit your claim to us within 30 days of the date from when you received the service, item, or drug.

Contact the Member Services Department if you have any questions or want to give us more information about a request you have already sent to us. We can help you if you don’t know what you should have paid or you have received a bill and you don’t know what to do about it.