Part D Appeals
Part D Appeals – What is an Appeal?
If you or your doctor disagree with our decision to say no to your request for coverage, you can appeal. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake.
Making an Appeal
If our answer is no to part or all of what you asked for, we will send you a letter that explains why we said no. The letter will also explain how you can appeal our decision. You must make your appeal within 60 days from the date on the letter we sent to you. This letter told you our answer to your request for coverage. If you have a good reason for sending your appeal after the 60 days, we might give you more time. If your health requires it, ask us to give you a “fast appeal.” A fast appeal is called an “expedited reconsideration” (Part C) or an “expedited redetermination” (Part D).
How to File an Appeal
Step 1: To ask for an appeal you have to tell us. The appeal can be from you, your representative, or your doctor.
Step 2: You can write, mail, fax or deliver your appeal, or you can call us.
For a Standard Appeal:
Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP)
Attn: Appeals and Grievances – Medicare Operations
7700 Forsyth Blvd
Saint Louis MO 63105
Phone: 1-866-896-1844 (TTY: 711)
If you ask in writing, your appeal must include your:
- Member number.
- Reasons for the appeal.
- Medical records, notes or a letter from your doctor.
- Other information that shows why you need the item or service. Call your doctor if you need this information.
What Do We Do When You File an Appeal?
We have a different doctor look at your case to see if we should change our mind. We may need more information from you or your doctor. We must make sure we have everything done on time. We will get your appeal done as fast as your health needs it, but no later than:
Prescription Drug (Part D) – Standard: 7 days
Prescription Drug (Part D) – Expedited: 72 hours
What Happens Next?
If we do not agree with your appeal, we will send you a letter. We will also send your case to an independent reviewer. An independent reviewer is a third-party reviewer called the Medicare Independent Review Entity or IRE. The IRE will send you a letter with a decision and tell you if you have more options.
For more information, call Member Services at 1-866-896-1844. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned the next business day. TTY users call 711.