Determinations, Grievances & Appeals
Capital Health Plan members have a right to ask for coverage determinations, exceptions, organization determinations and redeterminations, file appeals, file a complaint or grievance, and understand how CHP makes health care decisions to ensure quality treatment and efficient use of resources. This page contains information on the above and required steps you, your doctor, or your representative may need to take to complete a specific action.
Table of Contents
How to Request a Coverage Determination
As a CHP member, you have the right to ask for a Medicare Part D prescription drug benefit. The first step is called requesting a “coverage determination.” A form is available for you to use, although using the form is not required (Request for Medicare Prescription Drug Coverage Determination Form). When we make a coverage determination, we are making a decision whether to provide or pay for a Part D drug and what your share of the cost is for the drug. The following are examples of coverage determinations:
- You ask us to pay for a prescription drug that you have received. This is a request for coverage determination about payment.
- You ask for a Part D drug that is not on CHP’s list of covered drugs (called a “formulary”). This is a request for a “formulary exception.”
- You ask for an exception to our utilization management tools, such as prior authorization, dosage limits, quantity limits, or step therapy requirements. These are types of “formulary exceptions.”
- You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a “tiering exception.”
- You ask us to pay you back for a drug that you bought at an out-of-network pharmacy.
- Coverage determinations can include exceptions requests.
There are Three Kinds of Coverage Determinations That You Can Request
- Fast or Expedited (24 hours)
You can request a fast coverage determination:- If your doctor or other prescriber asks for a fast determination for you, or supports you in asking for one, and the doctor or other prescriber indicates that waiting for a standard determination could seriously harm your health or your ability to function, we automatically will give you a fast determination.
- If you ask for a fast coverage determination without support from a doctor or other prescriber; we will decide if your health requires a fast determination.
- Standard coverage decision about a drug you have not yet received (72 hours)
Any request for a Part D drug that you have not yet purchased and that does not need to be decided within 24 hours for protection of your health or ability to function will be decided as a standard determination. - Standard coverage decision about payment for a drug you have already purchased (14 calendar days)
Any request for payment for a Part D drug you have already purchased will be decided as a standard determination.
How to Request an Exception
An exception is a type of coverage determination. Whenever you request an exception, your doctor or other prescriber must submit a statement and supporting information about the medical need for the exception. A request for an exception will be approved only when there is a medical reason for it. If you request an exception, your doctor or other prescriber must provide a statement to support your request. You have the right to ask us for an “exception” if you want us to:
- Waive coverage restrictions on your drug
- Provide a higher level of coverage (and, thus, a lower copayment) for your drug
You can ask us to make the following exceptions to our coverage rules for Part D prescription drugs:
- Formulary Exception
You can make a request for an exception for drugs that have coverage restrictions, including quantity limits, step therapy requirements, and prior authorization. You may ask for coverage of a Part D drug that is not on Capital Health Plan’s formulary. If the exception is approved, arrangements will be made to cover the drug for the remainder of the plan year up to your pharmacy benefit limit, and you will be notified of the approval. If the exception is denied, you will be notified of the decision and given information about your appeal rights. - Tiering Exception
You can ask us to provide a higher level of coverage for your drug. If the exception is approved, arrangements will be made to cover the requested drug at the Tier 2 copayment for the remainder of the plan year up to your pharmacy benefit limit, and you will be notified of the approval. If the exception is denied, you will be notified of the decision and given information about your appeal rights.
Capital Health Plan will notify you and your doctor or other prescriber of our decision about a standard request for an exception as quickly as your health condition requires, but no later than 72 hours after we receive the required information from your doctor or other prescriber. Our notification will be given within 24 hours after we receive the required information from your doctor or other prescriber if he or she indicates that waiting for a standard determination could seriously harm your health or your ability to function. If your doctor or other prescriber does not provide us with the required information, we will wait up to 45 days before we make our decision. If your doctor or other prescriber does not provide the requested information within 45 days, we will make our decision with the information that we have.
If we receive the supporting statement from your doctor or other prescriber and we do not provide a timely response, your request automatically is sent for review to an Independent Review Organization.
Please see Part D Exceptions here for details on the Medicare Part D exceptions process.
How Do I Request for Medicare Prescription Drug Coverage Redetermination?
Download the Request for Redetermination of Medicare Prescription Drug Denial Form to request a redetermination.
What If I Am Asking for a Standard Decision?
Then you, your doctor or other prescriber, or your appointed representative may contact our various Member Services Teams by telephone or fax at the numbers below:
Telephone:
Medicare Member Services: (850) 523-7441 or 1 (877) 247-6512; 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members call 1-877-392-1532, 7:00 a.m. – 8:00 p.m.
Non-Medicare Member Services: (850) 383-3311 or 1 (877) 247-6512, 8:00 a.m. – 5:00 p.m., Monday – Friday
State of Florida Member Services: 1 (877) 392-1532; 7:00 a.m. – 7:00 p.m., Monday – Friday
Fax:
800-693-6703
Email:
[email protected]
Deliver:
Member Services – 3rd Floor
1264 Metropolitan Blvd.
Tallahassee, FL 32312
Asking for a fast decision: You, your doctor or other prescriber, or your appointed representative may contact us by telephone or fax at the numbers above. Be sure to ask for a “fast,” “expedited,” or “24-hour” review.
How to Request an Organization Determination
To ask for an organization determination, you or your doctor may call CHP Member Services, fax, mail, or deliver a written request using the contact information below. If you or your doctor believe waiting for a standard decision could seriously harm your health or your ability to function, you may ask for a “fast” or “72-hour” decision.
Mail:
Capital Health Plan
Attention: Member Services
P.O. Box 15349
Tallahassee, FL 32317-5349
Deliver:
Capital Health Plan
Member Services
1264 Metropolitan Blvd.,
Tallahassee, FL 32312
Telephone:
(850) 523-7441 or 1 (877) 247-6512; 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members call 1-877-392-1532, 7:00 a.m. – 8:00 p.m.
Email:
[email protected]
Fax:
850-383-3310
CHP will review your request and make an organization determination within the following timeframes:
- For a decision about payment for services that you already have received – 30 days.
A decision can take up to 30 additional days if we find that some information is missing that may benefit you or if you need more time to prepare for this review. - For a decision about services you have not received – 14 days.
A decision can take up to 14 additional days if we find that some information is missing that may benefit you or if you need more time to prepare for this review. - For a “fast” decision about services you have not received – 72 hours.
A decision can take up to 14 additional days if we find that some information is missing that may benefit you or if you need more time to prepare for this review.
How Do I File a Complaint?
You may make a complaint if you have concerns or problems with CHP or one of our providers. A complaint will be handled as an “appeal” or a “grievance,” depending on the subject of the complaint.
An “appeal” is a review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision that we have made. For example, a decision we have made about a medical service or treatment. You cannot request an appeal if we have not issued a formal decision.
A “grievance” is any complaint other than one that involves a coverage determination. For example, you would file a grievance if you have a problem such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by telephone or get the information that you need, or the cleanliness or condition of a network pharmacy.
Instructions for Filing Appeals
If we deny your request, we will send you a written decision explaining the reason(s). If we deny all or any part of your request in our organization determination, you may ask us to reconsider our decision. This is called an “appeal” or “request for reconsideration.” If you need help filing your appeal, please contact us at the phone numbers listed below. You must appeal our denial within 65 calendar days of the date on the notice of our organization determination. We can give you more time if you have a good reason for missing the deadline.
There Are Three Kinds of Appeals That You Can File:
- Fast (72-hour review)
You can ask for a fast appeal if you or your doctor believe that your health could be seriously harmed by waiting too long for a decision. We must decide on a fast appeal no later than 72 hours after we get your appeal. We may extend this time by up to 14 days if you request an extension or if we need additional information and the extension benefits you.- If any doctor asks for a fast appeal for you, or supports you in asking for one, and the doctor indicates that waiting for 30 days could seriously harm your health, we automatically will give you a fast appeal.
- If you ask for a fast appeal without support from a doctor, we will decide if your health requires a fast appeal. If we do not give you a fast appeal, we will decide your appeal within 30 days.
- Standard Request for Service (30 days) or (7 days) for Medications Administered Under the Medical Benefit
You can ask for a standard appeal that we authorize or approve a service that you have not yet received. We must give you a decision no later than 30 days after we get your appeal. (We may extend this time by up to 14 days if you request an extension or if we need additional information and the extension benefits you.) - Standard Request for Payment (60 days)
You can ask for a standard appeal requesting payment for a service you have already received. We must give you a decision no later than 60 days after we get your appeal.
What Do I Include With My Appeal?
You should include your name, address, member ID number, reasons for appealing, and any evidence that you wish to attach. You may include supporting medical records, doctors’ letters, or other information that explains why we should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.
If your appeal relates to a decision by us to deny a drug that is not on our list of covered drugs (formulary), your doctor or other prescriber must indicate that all of the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health.
How Do I File An Appeal?
For a Standard Appeal: You, your doctor, or your appointed representative (Appointment of Representative Form) should mail, fax, or deliver your written appeal.
Mail:
Capital Health Plan
Attention: Grievances/Appeals
P.O. Box 15349
Tallahassee, FL 32317-5349
Deliver:
Capital Health Plan
Member Services
1264 Metropolitan Blvd.,
Tallahassee, FL 32312
For a Fast Appeal: You, your doctor, or your appointed representative should contact us by telephone or fax:
Telephone:
Medicare Member Services: (850) 523-7441 or 1 (877) 247-6512; 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members call 1-877-392-1532, 7:00 a.m. – 8:00 p.m.
Non-Medicare Member Services: (850) 383-3311 or 1 (877) 247-6512, 8:00 a.m. – 5:00 p.m., Monday – Friday
State of Florida Member Services: 1 (877) 392-1532; 7:00 a.m. – 7:00 p.m., Monday – Friday
Fax:
850-383-3413
What Happens Next?
If you appeal, we will review our decision. If we continue to deny any of the services that you requested, Medicare will automatically provide you with a new and impartial review of your case by a reviewer outside of CHP. If you disagree with the decision of the outside reviewer, you will have further appeal rights. You will be notified of those appeal rights if this happens.
Commercial members may request an independent external review. The instructions for how to do so will be provided with the appeal decision.
Instructions for Filing Grievances
A “grievance” is the type of complaint that you make if you have any type of problem with CHP or one of our plan doctors and providers that does not relate to a coverage decision.
How Do I Submit a Grievance?
You or your appointed representative (Appointment of Representative Form) may call CHP Member Services, fax, mail, or deliver a written grievance using the contact information below. If you submit a verbal grievance that is not quality of care related, you will get an answer by telephone, unless you ask for an answer in writing. All quality of care grievances will be answered in writing.
For an Expedited Grievance: You or your appointed representative should contact us by telephone or fax at the numbers below:
Telephone:
(850) 523-7441 or 1 (877) 247-6512; 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members call 1-877-392-1532, 7:00 a.m. – 8:00 p.m.
Fax:
850-383-3413
For a Standard Grievance: You or your appointed representative (Appointment of Representative Form) should call, mail, or deliver your grievance request to the address/number below:
Mail:
Capital Health Plan
Attention: Member Services
P.O. Box 15349
Tallahassee, FL 32317
Deliver:
Capital Health Plan
Member Services – 3rd Floor
1264 Metropolitan Blvd.,
Tallahassee, FL 32312
Email:
[email protected]
There are Two Kinds of Grievances That You Can Request:
- Standard (30 days)
We must respond to this type of grievance as promptly as your medical condition requires, but no later than 30 calendar days from the date we receive it. - Fast (24 hours)
This is for if you disagree with our decision not to give you a fast decision on medical care, or if you disagree with our decision to take a time extension on initial decisions or appeals. We must respond to this type of grievance within 24 hours of the time we receive it.
Quality of Care Complaints
If you are concerned about the quality of care that you received, you can submit a written complaint to the following independent organization:
ACENTRA HEALTH
5201 W. Kennedy Blvd., Suite 900
Tampa, FL 33609
Phone: 1-888-317-0751, Fax: 1-833-868-4058, TTY: 1-855-843-4776
Important Forms for Filing Grievances and Appeals
If you need information or help, or would like to obtain an aggregate number of grievances and appeals filed with a specific plan, call us at:
(850) 523-7441 or 1 (877) 247-6512 (TTY 850-383-3534 or 1-877-870-8943) 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members can call 1-877-392-1532, 7:00 a.m. – 8:00 p.m.
Utilization Management
Capital Health Plan makes health care decisions to ensure quality treatment and efficient use of resources. We conduct regular evaluations of emerging medical technologies, including drugs, procedures, and devices, to determine coverage eligibility. Members and healthcare providers can request the assessment of new technologies at any time.
To better understand how CHP makes health care decisions, along with evaluating new technology to ensure quality treatment and efficient use of resources, read below.
Understanding Capital Health Plan’s Health Care Decision-Making
CHP reviews medical literature and seeks the input of appropriate specialists to develop clinical review standards for coverage of certain health care services. These clinical guidelines are available to members and participating doctors/providers. CHP’s participating physicians use the clinical review standards to help determine when a member needs health care services, medication, and supplies, and which services, medication, and supplies are suitable. A primary care physician or participating doctor/provider may request that CHP review, for coverage purposes, whether a member meets clinical standards for a specific service, medication, or supply. CHP may also proactively evaluate specific services, medication, or supplies to determine coverage by the member’s plan. The requested services and supplies must support the diagnosis and treatment of the member’s condition and standards of good medical practice. The review process may be:
- Urgent (a service that if not quickly decided could seriously jeopardize the member’s health or ability to regain maximum function)
- Pre-Service (approved in advance of obtaining medical care, such as precertification, prior approval, and required authorization)
- Post-Service (after service is provided)
- Concurrent Care Decisions (provide continued coverage of approved ongoing treatment while an internal appeal is pending; this situation may also be submitted as Urgent)
If you have questions about utilization management procedures, decisions, or your benefits, you can contact our Member Services Team.
CHP safeguards confidential information and makes disclosures only when allowed under state and federal law, including HIPAA. Information used in the decision-making process is protected by CHP staff members who must use the information.
CHP’s policy statement for utilization management decisions:
- Utilization management decisions are based only on the appropriateness of care and services according to the clinical standards, and the existence of benefit coverage.
- CHP does not reward reviewers or provide financial incentives to deny coverage or care.
- CHP does not offer incentives to encourage decisions that result in underutilization.
A member, physician, or person authorized by a member may request a re-evaluation of a utilization management decision as follows:
- By sending to CHP’s Appeal Department a written request to review a previous coverage or payment decision, which is known as an appeal.
- Staff collects any necessary documents, and the member request is reviewed by a team of senior managers and physicians. CHP notifies the member in a timely manner of the review group’s decision.
- By requesting an expedited appeal decision.
- Expedited decisions are only those made when a delay in an appeal decision for care that has not occurred would harm the member’s health. A call to Medicare Member Services alerts CHP to make an expedited appeal decision. Staff will then notify the member when the decision has been made.
- By asking for an evaluation by an organization outside of CHP if dissatisfied with the appeal decision.
- The Independent Review Organization is an independent organization that is hired by Medicare. The organization is not connected with CHP and is not a government agency. The organization is a company chosen by Medicare to review CHP’s decisions about Medicare benefits. Members pay nothing for independent reviews, and CHP must accept decisions made by independent review organizations. The letter that notifies the member of the appeal decision explains how to request an independent review.
CHP regularly reviews new medical technologies (drugs, procedures, and devices) for coverage. Members and doctors/providers may ask at any time for consideration of new technology. To make decisions, CHP’s medical director reviews research by relevant specialists and information from government regulatory bodies, Medicare manuals, and medical journals.
The standards for approval include:
- Final acceptance by the proper government regulatory body
- Testing that shows a positive effect on health
- Improved health outcomes at least as helpful as any established option
- Improved outcomes outside the investigational setting
If you need information or help, or would like to obtain an aggregate number of grievances and appeals filed with this plan, Medicare Members can call: (850) 523-7441 or 1 (877) 247-6512; 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members call 1-877-392-1532, 7:00 a.m. – 8:00 p.m.
Non-Medicare Members can call (850) 383-3311 or 1 (877) 247-6512, 8:00 a.m. – 5:00 p.m., Monday – Friday
State of Florida Membes can call 1 (877) 392-1532; 7:00 a.m. – 7:00 p.m., Monday – Friday