Medicare : Member Rights

 

What to do if you have a problem or concern:

Please call us first

 

Your health and satisfaction are important to us. When you have a problem or concern, please call our Customer Service. We will work with you to try to find a satisfactory solution to your problem. Please see below for phone numbers, addresses and/or fax numbers for different types of problems or concerns.

 

However, if for some reason your issue isn’t settled to your satisfaction, there are formal steps you can take. You have rights as a member of our plan and as someone who is getting Medicare. We pledge to honor your rights, to take your problems and concerns seriously, and to treat you with fairness and respect.

 

Please read our Evidence of Coverage for more information. See the section titled "What to do if you have a problem or complaint (coverage decisions, appeals, complaints).”

 

There are two types of formal processes for handling problems and concerns:

 

 

Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures and deadlines that must be followed by us and by you.

 

Coverage decisions and appeals

The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for medical services and prescription drugs, including problems related to payment, This is the process you use for issues such as whether something is covered or not and the way in which something is covered.

 

Asking for coverage decisions

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

 

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

 

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who make the original unfavorable decision. When we have completed the review, we give you our decision.

 

You, an independent organization that is not connected with our plan (State Health Insurance Assistance Program), doctor or other provider, someone else to act on your behalf or your lawyer may ask us for a coverage decision or appeal a decision. If you want a friend, relative, your doctor or other prescriber, or other person to be your representative, you need to complete the Appointment of Representive form that gives that person permission to act on your behalf. You must give us a copy of the signed form.

 

When to ask for a Coverage Decision for Medical Services (Part C)

 

If you are in any of the following situations you ask for a medical coverage decision:

 

• You are not getting certain medical care you want and you believe that this care is covered by our plan.
• Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan.
• You have received medical care or services that you believe should be covered by the plan, but we have said we will not pay for this care.
• You have received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care.
• You are being told that coverage for certain medical care you have been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.

 

You can ask for a decision about Part C (medical care) coverage on one of the following ways:

 

• Call: Click here for the correct phone number for your plan and state
• Fax: 1-813-262-2802
• Write: WellCare, Coverage Determinations -Medical, P.O. Box 31370 Tampa, FL 33631

 

What is an exception (Part D)?

If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception.” An exception is a type of coverage decision. Similiar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

 

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception to be approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:

1. Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary). (We call it the “Drug List” for short.) You cannot ask for coverage of any “excluded drugs” or other non-Part D drugs that Medicare does not cover. 
2. Removing a restriction on our coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on our List of Covered Drugs (Formulary).
3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on the plan's Drug List is in one of the cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug.

 

Important things to know about asking for exceptions

 

Your doctor or other prescriber must give us a written exception that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception. Typically our Drug List includes more than one drug for treating a particular condition. These different possibilities are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception.

 

You can ask for a coverage decision and/or exception by one of the four following ways: 

 

• Complete our online Request for Medicare Prescription Drug Coverage Determination form.
• Fax: 1-866-388-1767
• Call: Click here for the correct phone number for your plan and state
• Write: WellCare, Pharmacy-Coverage Determinations, P.O. Box 31397, Tampa, FL 33631-3397
  • Overnight Address: WellCare, Pharmacy-Coverage Determinations, 8735 Henderson Road, Ren. 4, Tampa, FL 33634

 

These forms can help you ask for a coverage decision:

 

• 'Ohana Injectable Infusion
• Online Form: Request for Medicare Prescription Drug Coverage Determination (Provider & Member)
• Request for Medicare Prescription Drug Coverage Determination  (Provider & Member)

 

How to make an appeal?

 

To start your appeal, you, your doctor or your representative must contact our plan. If you are asking for a standard appeal, make your appeal by submitting a written request. If you are asking for a fast appeal, you may make your appeal in writing or calling us at the number listed below. You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you of our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

 

If your health requires it, ask for a "fast appeal." If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it. If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for "fast" appeal.

 

There are three ways to file an appeal for Part C Determination:

 

• Call: Click here for the correct phone number for your plan and state
• Fax: 1-866-201-0657
• Write: WellCare, Appeals Department, P.O. Box 31368, Tampa, FL 33631-3368
  • Overnight Address: WellCare, Appeals Department, 8735 Henderson Road, Ren. 4, Tampa, FL 33634

 

There are four ways to file an appeal for Part D Determination:

 

• Complete our online Request for Redetermination of Medicare Prescription Drug Denial (Appeal) form.
• Call: Click here for the correct phone number for your plan and state
• Fax: 1-866-388-1766
• Write: WellCare, Pharmacy Appeals Department, P.O. Box 31383, Tampa, FL 33631-3383

 

You may download the following form to use on your appeal:
  

• Online Form: Request for Redetermination of Medicare Prescription Drug Denial (Appeal)
• Request for Redetermination of Medicare Prescription Drug Denial (Appeal) 

 

Independent Review Organizations; also known as Independent Review Entity (IRE)

If our plan says no to your appeal, you then can choose whether to accept this decision or continue making another appeal. If you decide to go on to a Level 2 appeal, the Independent Review Organization reviews the decision our plan made when we said no to your first appeal. This organization decides whether the decision we made should be changed. The Independent Review Organization an independent organization that is hired by Medicare. 

 

Member complaints/grievances

 

The formal name for “making a complaint” is “filing a grievance.”  The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. You can file a grievance or someone you authorize can do so on your behalf.

 

If you have any of these kinds of problems, you can "make a complaint":

 

• You are unhappy with the quality of the care you received.
• You believe that someone did not respect your right to privacy or shared information you feel should be confidential
• You were disrespected, received poor customer service or other negative behaviors
• You were kept waiting too long
• You are unhappy with the cleanliness or condition of a hospital, doctor's office or pharmacy
• The information you get from us is incorrect or hard to understand 

 

Your health and satisfaction are important to us. Usually calling our Customer Service at the number listed at the top of this page is the first step. If you do not wish to call (or you called and were not satisfied) you can put your complaint in writing and send it to us. The complaint must be made within 60 days after you had the problem you want to complain about.

 

As a member of our plan, you have the right to file an expedited grievance (fast complaint) for specific circumstances.  See our Evidence of Coverage for more information.  An expedited grievance (fast complaint) is resolved within 24 hours. A standard grievance is generally resolved within 30 days from the date we receive your request unless your health or condition requires a quicker response. If additional information is required or you can ask for an extension, we may extend that timeframe by up to 14 days.

 

If you are making a complaint because we denied your request for a “fast response” to a coverage decision or appeal, we will automatically give you a “fast complaint.” If you have a fast complaint, we will give you an answer within 24 hours.

 

You file a grievance in one of the four following ways:

 

• Call: Click here for the correct phone number for your plan and state
• Fax: 1-866-388-1769
• Write: WellCare, Grievance Department, P.O. Box 31384, Tampa, FL 33631-3384
• Email to: PDPgrievance@wellcare.com

  

Quality Improvement Organizations

 

You can make your complaint to the Quality Improvement Organization (QIO). If you prefer, you can also make complaint about the quality of care you received directly to this organization (without making a complaint to us). To find the name, address, and phone number of the Quality Improvement Organization in your state, please read your Evidence of Coverage. If you make a complaint to this organization, we will work together with them to resolve your complaint.

  

If you would like information on how to obtain an aggregate number of grievances, appeals, and exceptions filed with our plan, contact us for more information.

Last modified: 03/12/2012