Request for Redetermination of Medicare Prescription Drug Denial
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- Lisa Caren Beasley
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1 Request for Redetermination of Medicare Prescription Drug Denial Because we Blue Cross Medicare Advantage Dual Care (HMO SNP) SM denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. This form may be sent to us by mail or fax: Address: Fax Number: Blue Cross Medicare Advantage SM Attn: Clinical Review Department 1305 Corporate Center Dr, Bldg N10 Eagan, MN You may also ask us for an appeal through our website at Expedited appeal requests can be made by phone at, TTY/TDD 711, we are open 8:00 a.m. 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voic ) will be used on weekends and holidays. Who May Make a Request: Your prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Contact us to learn how to name a representative. Enrollee s Information Enrollee s Name Date of Birth Enrollee s Address Phone Enrollee s Plan ID Number Complete the following section ONLY if the person making this request is not the enrollee: Requestor s Name Requestor s Relationship to Enrollee Address Phone Representation documentation for appeal requests made by someone other than enrollee or the enrollee s prescriber: Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted at the coverage determination level. For more information on appointing a representative, contact your plan or Medicare (24 hours a day / 7 days a week). Y0096_APG_NMSNPRDTReqForm17
2 Prescription drug you are requesting: Name of drug: Strength/quantity/dose: Have you purchased the drug pending appeal? Yes No If Yes : Date purchased: Amount paid: $ (attach copy of receipt) Name and telephone number of pharmacy: Prescriber's Information Name Address Office Phone Fax Office Contact Person Important Note: Expedited Decisions If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received. CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS If you have a supporting statement from your prescriber, attach it to this request. Please explain your reasons for appealing. Attach additional pages, if necessary. Attach any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records. You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage. Signature of person requesting the appeal (the enrollee, or the enrollee s prescriber or representative): Date:
3 This information is available for free in other languages. Please call our Customer Service number at (TTY/TDD users should call 711). We are open between 8:00 a.m. and 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voic ) will be used on the weekends and holidays. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al cliente al (los usuarios de TTY/TDD deben llamar al 711). Nuestro horario es de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 de septiembre, durante los fines de semana y feriados, se usarán tecnologías alternas (por ejemplo, correo de voz). Blue Cross Medicare Advantage Dual Care is an HMO Special Needs Plan provided by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association. HCSC is a Medicare Advantage organization with a Medicare contract and a contract with the New Mexico Medicaid program. Enrollment in HCSC's plan depends on contract renewal.
4 Blue Cross and Blue Shield of New Mexico complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of New Mexico does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of New Mexico: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Civil Rights Coordinator If you believe that Blue Cross and Blue Shield of New Mexico has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, , TTY/TDD: , Fax: , Civilrightscoordinator@hcsc.net. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Y0096_MRK_NM_NDNOTICE17 Accepted
5 ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Díí baa akó nínízin: Díí saad bee yáníłti go Diné Bizaad, saad bee áká ánída áwo dę ę, t áá jiik eh, éí ná hólǫ, kojį hódíílnih (TTY: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) ملحوظ: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل رقم (رقم هاتف الصم والبكم: ( 711 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. (TTY: 711) 번으로전화해주십시오. PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 711). ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ध य न द : दद आप ह द ब लत त आपक ललए म फत म भय षय स य तय स वय ए उपलब ध (TTY: 711) पर क ल कर توجه: اگر به زبان فارسی گفتگو می کنيد تسهيالت زبانی به صورت رايگان برای شما فراهم می باشد. با تماس بگيريد. 711) (TTY: เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711).
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