Request for Redetermination of Medicare Prescription Drug Denial
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- Alyson West
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1 Request for Redetermination of Medicare Prescription Drug Denial Because we [Part D plan sponsor] 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: Kaiser Foundation Health Plan of Georgia Attention: Appeals and Grievances Unit Nine Piedmont Center 3495 Piedmont Rd. Atlanta, GA You may also ask us for an appeal through our website at kp.org. Expedited appeal requests can be made by phone at 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. Y0043_N CMS Approved (12/12/2011)
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: Y0043_N CMS Approved (12/12/2011)
3 Notice of nondiscrimination Kaiser Foundation Health Plan of Georgia, Inc. (Kaiser Health Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters. Written information in other formats, such as large print, audio, and accessible electronic formats. Provide no cost language services to people whose primary language is not English, such as: Qualified interpreters. Information written in other languages. If you need these services, call Member Services at (TTY 711), 8 a.m. to 8 p.m., seven days a week. If you believe that Kaiser Health Plan 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 our Civil Rights Coordinator by writing to Attention: Member Services, Nine Piedmont Center, 3495 Piedmont Road NE, Atlanta, GA or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our 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, DC 20201, , (TDD). Complaint forms are available at Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. H1170_1557nondis accepted
4 Multi-language Interpreter Services English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Chinese 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) Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Japanese 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 Amharic ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (መስማት ለተሳናቸው: 711). H1170_016_11 accepted
5 Farsi توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات باشد. با( 711 (TTY: تماس بگیری زبانی بصورت رایگان برای شما می فراھم Arabic ملحوظة: إذا كنت ت حدثت اذكر اللغة ف خدماتا ن ھاتف الصم والبكم: بالمج ن.ا لك تتوافر اللغویة دة المس عا اتصل برقم رقم(.(117 German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Portuguese ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). French Creole ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711).
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