What is an Appeal?
An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.
Appeal Level 1: If we deny part or all or part of your request in our coverage determination, you may ask us to reconsider our decision. This is called an "appeal" or "request for redetermination."
Please call us at 1-800-777-4376 (TTY 1-800-947-3529) if you need help with filing your appeal. You may ask us to reconsider our coverage determination, even if only part of our decision is not what you requested. When we receive your request to reconsider the coverage determination, we give the request to people at our organization who were not involved in making the coverage determination. This helps ensure that we will give your request a fresh look.
How you make your appeal depends on whether you are requesting reimbursement for a Part D drug you already received and paid for, or authorization of a Part D benefit (that is, a Part D drug that you have not yet received). If your appeal concerns a decision we made about authorizing a Part D benefit that you have not received yet, then you and/or your doctor will first need to decide whether you need a fast appeal. The procedures for deciding on a standard or a fast appeal are the same as those described for a standard or fast coverage determination. Please see the discussion under "Do you have a request for a Part D prescription drug that needs to be decided more quickly than the standard timeframe?" and "Asking for a fast decision."
How Would I ask for an Appeal?
To ask for an appeal, you, your doctor, or your appointed representative should call us at 1-800-777-4376 (TTY: 1-800-947-3529). Or, you can deliver a written request to Independent Care Health Plan, 1555 N. RiverCenter Dr, Suite 206, Milwaukee, WI 53212 or fax it to 414-231-1092.
You may print this form and send it to iCare.
Redetermination Request Form
What if You Want A Fast Appeal?
The rules about asking for a fast appeal are the same as the rules about asking for a fast coverage determination. You, your doctor, or your appointed representative can ask us to give a fast appeal (rather than a standard appeal). Remember, that if your prescribing physician provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically treat you as eligible for a fast appeal. For information on how to submit an appeal, see the section above (How Would I ask for an Appeal?).
What Information Should I Gather to Support my 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. 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 can give us your additional information in any of the following ways:
- In writing, to Independent Care Health Plan, 1555 N. RiverCenter Dr., Suite 206, Milwaukee, WI 53212.
- By fax, at (414) 231-1092.
- By telephone – if it is a fast appeal – at 1-800-777-4376 (TTY 1-800-947-3529).
- In person, at 1555 N. RiverCenter Dr, Suite 206.
You also have the right to ask us for a copy of information regarding your appeal. You can call or write us at 1-800-777-4376 (TTY 1-800-947-3529), Independent Care Health Plan, 1555 N. RiverCenter Dr., Suite 206, Milwaukee, WI 53212.
Who May File an Appeal of the Coverage Determination?
The rules about who may file an appeal are the same as the rules about who may ask for a coverage determination. An appeal may be filed by you, your appointed representative, or your prescribing physician.
How Soon Must I File My Appeal?
You need to file your appeal within 60 calendar days from the date included on the notice of our coverage determination. We can give you more time if you have a good reason for missing the deadline.
How Soon Must iCare Decide On Your Appeal?
How quickly we decide on your appeal depends on the type of appeal:
1. For a standard decision about a Part D drug, which includes a request for reimbursement for a Part D drug you already paid for and received: we have up to 7 calendar days to give you a decision, but will make it sooner if your health condition requires us to. If we do not give you our decision within 7 calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case.
2. For a fast decision about a Part D drug that you have not received: we have up to 72 hours to give you a decision, 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 Appeal Level 2, where an independent organization will review your case.
- What Happens Next if iCare Decides Completely in my Favor?
- We must send payment to you no later than 30 calendar days after we receive your request to reconsider our coverage determination.
- We must authorize or provide you with the Part D drug you have asked for as quickly as your health requires, but no later than 7 calendar days after we received your appeal. We must authorize or provide you with the Part D drug you have asked for within 72 hours of receiving your appeal – or sooner, if your health would be affected by waiting this long.
- What Happens Next if my Appeal is Denied?
If we deny any part of your appeal, you or your appointed representative have the right to ask an independent organization, to review your case. This independent review organization contracts with the federal government and is not part of iCare's Medicare Plan.
If you would like to inquire about the status of a coverage determination, please call Customer Service at 1-800-777-4376 (TTY 1-800-947-3529).
See your Evidence of Coverage, Section 11, "Appeals and Grievances: What To Do If You Have Complaints About Your Part D Prescription Drug Benefits," for more information.
How Would I Contact Medicare For Assistance?
To contact Medicare for assistance directly, please use this link: Medicare Complaint Form.