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Appeal process for prescription drugs

An appeal is your opportunity to request a redetermination of an adverse coverage determination, which includes denied exception requests.

Example of an appeal:
If we deny your request for an exception to cover a non-formulary drug, then you may file an appeal of the denial. An appeal can only be filed after an exception has been requested and denied by the Plan.

How do I file an appeal?

If you receive a coverage determination denial, you or your appointed representative may file an appeal. A specific form is not required for you to file an appeal. An appeal must be filed within 60 calendar days of the date of the denial notice and must be in writing, unless you are filing an expedited or fast appeal. You may submit it via:

Mail:
Blue Medicare HMO or Blue Medicare PPO
Attn: Appeals and Grievance Unit
P.O. Box 17509
Winston-Salem, NC 27116-7509

Blue Medicare Rx
Attn: Appeals and Grievance Unit
P.O. Box 17168
Winston-Salem, NC 27116-7168

Fax:
(336) 794-8836
(888) 375-8836

In-person:
Blue Medicare HMO, Blue Medicare PPO or Blue Medicare Rx
5660 University Parkway
Winston-Salem, NC 27105
Mon. - Fri., 8 a.m. - 5 p.m.

When will I receive a decision on my appeal?

We will perform a standard review of your appeal as soon as your health requires but no later than seven (7) calendar days after we receive your appeal. We will review requests for an expedited or fast appeal as soon as possible, but no later than 72 hours following our receipt of the request. An individual who was not involved with your original coverage determination will make a decision on your appeal.

You will receive a written response to your appeal. The decision on an expedited appeal will be provided by phone followed by the written notice. If our decision is to deny the appeal, the notice will advise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructions on how to do so. If we miss our timeframes for claims adjudication or review of the appeal, we will automatically forward the appeal to the IRE for a decision. There may be additional levels of appeal available to you. We will inform you of your additional rights in the notice, or you may refer to your Evidence of Coverage for further details.

Appointing a representative

A Medicare beneficiary may appoint an individual to act as his/her representative in filing an appeal. A representative who is appointed by the court or who is acting in accordance with North Carolina law may also file an appeal. An appeal by a representative is not valid until the Appointment of Representative form below is completed and submitted, or other equivalent form, legal papers or authority are submitted.

Appointment of Representative form

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Blue Medicare HMO and Blue Medicare PPO plans are offered by PARTNERS National Health Plans of North Carolina, Inc. (PARTNERS), a subsidiary of Blue Cross and Blue Shield of North Carolina (BCBSNC). PARTNERS is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. Plans are administered by BCBSNC. BCBSNC and PARTNERS do not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or another third party. BCBSNC and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association.

The information on this page is current as of 11/4/08.