PART D APPEALS
If you disagree with the outcome of a coverage determination, you, your Appointed Representative, or your prescribing physician may file an appeal called a plan “redetermination”. You must ask for it within 60 days from the date of our denial notice, unless you can show good cause for delay. Please refer to your Evidence of Coverage located on the 2022 Plan Documents page that discusses the five (5) levels of appeals. When our plan is reviewing your appeal, we take another careful look at all the information about your initial coverage request. You also have the right to give us new information supporting your appeal request. We also reevaluate if we were being fair and following all the rules when we said no to your initial request. We may contact you or your doctor or other prescriber to get more information.
How to request a Part D appeal
You or your Appointed Representative (your doctor, attorney, advocate, relative, friend, or other person authorized to act on your behalf) can submit an online Part D appeal request, fax, or mail a request for a standard redetermination.
- ONLINE: To submit your Part D appeal request online, please click here.
- FAX: To fax your Part D appeal request, complete the correct coverage determination request form and fax to Elixir at 1-877-503-7231. These forms can be found on the Formulary Restrictions page. If you’re not sure which form to use, you can complete a general request form called the Request for Medicare Prescription Drug Coverage Determination Form.
- MAIL: Please complete the correct coverage determination request form which can be found on the Formulary Restrictions page. If you’re not sure which form to use, you can complete a general request form called the Request for Medicare Prescription Drug Coverage Determination Form. Once completed, mail your coverage determination request to:
Elixir
Attn: Coverage Determinations
2181 E. Aurora Road, Suite 201
Twinsburg, OH 44087
- PHONE: To file an expedited Part D appeal request by phone
HealthTeam Advantage Plan I and Plan II PPO members call Elixir at 1-844-846-8003
HealthTeam Advantage Diabetes & Heart Care HMO members call Elixir at 1-833-684-7256
PLEASE NOTE: Those not authorized, under state law, to act for you must first sign an Appointment of Representative form and either fax to Elixir at 1-877-503-7231 or mail it to the below address:
Elixir
Attn: Coverage Determinations
2181 E. Aurora Road, Suite 201
Twinsburg, OH 44087
How long it takes for a Part D appeal decision
A standard appeal decision will be made within seven calendar days. If our decision is fully in your favor, we must authorize the service within seven days and/or make the payment within 14 calendar days.
If waiting for a standard decision could seriously harm your health or compromise your ability to regain maximum function, you or your prescribing doctor may request an expedited appeal for a decision within 72 hours. This process does not apply to denied claims for payment.
Status requests
For questions regarding the process or status of a Part D appeal request, you, your physician, or your appointed representative should call:
HealthTeam Advantage Plan I and Plan II PPO members call Elixir at 1-844-846-8003
HealthTeam Advantage Diabetes & Heart Care HMO members call Elixir at 1-833-684-7256
PART D GRIEVANCES
A grievance is any dispute other than one that involves a coverage determination that expresses dissatisfaction with the operations, activities or behavior of HealthTeam Advantage or one of our providers. For example, a grievance can involve the behavior of a network pharmacist, the ability to get the information you need from a customer service representative, or the condition of a network pharmacy.
You must file a grievance within 60 days from the date of the event that led to the complaint. Expedited or fast grievances will be responded to within 24 hours if the grievance is related to the plan’s refusal to make a fast coverage determination or redetermination and you haven’t purchased or received the drug. We’ll address other grievance requests within 30 days after receiving your complaint. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days to answer your complaint.
How to file a Part D Grievance
- PHONE/VERBAL: If you’d like to file a verbal grievance by phone, HealthTeam Advantage Plan I and Plan II PPO members call your Healthcare Concierge at 1-888-965-1965 (TTY: 711); HealthTeam Advantage Diabetes & Heart Care HMO members call your Healthcare Concierge at 1-888-965-1965 (TTY:711) October 1–March 31, 8 a.m. to 8 p.m. ET, 7 days a week or April 1–September 30, 8 a.m. to 8 p.m. ET, Monday through Friday.
If you request a written response to your phone complaint, we’ll respond in writing. - WRITTEN: If you’d like to file a written grievance, please send to one of the following:
- Fax: 800-845-4104
- Mail:
HealthTeam Advantage
Attn: Part D Appeals and Grievances
7800 McCloud Road, Suite 100
Greensboro, NC 27409
For more information, you can call your HealthTeam Advantage Healthcare Concierge at the number listed above.
Status requests
For questions regarding the process or status of a Part D appeal request, you, your physician or your appointed representative should call your Healthcare Concierge October 1–March 31, 8 a.m. to 8 p.m. ET, seven days a week or April 1–September 30, 8 a.m. to 8 p.m. ET, Monday through Friday.
HealthTeam Advantage Plan I and Plan II PPO members call your Healthcare Concierge at 1-888-965-1965 (TTY: 711)
HealthTeam Advantage Diabetes & Heart Care HMO members call your Healthcare Concierge at 1-888-965-1965 (TTY:711)
HealthTeam Advantage tracks and maintains records about the receipt and handling of grievances, appeals and exceptions. We’ll also disclose grievances, appeals and exceptions data to you upon request. To obtain this data, please call the HealthTeam Advantage Healthcare Concierge at the phone number listed above.
Complaints and disenrollment
If you have a complaint, you can complain to Medicare. You can also end your enrollment. To do that, refer to the information about disenrollment on the Your Rights page.