Member Rights and Responsibilities

 

Initial Determinations, Appeals, and Grievances

 

Initial Determinations

The initial determination we make is the starting point for dealing with requests you may have about covering a Part D drug and/or Part C medical care or service you need, or paying for a Part D drug and/or Part C medical care or service you already received. Initial decisions about Part D drugs are called "coverage determinations”. Initial decisions about Part C medical care or services are called "organization determinations". With this decision, we explain whether we will provide the Part D drug and/or Part C medical care or service you are requesting, or pay for the Part D drug and/or Part C medical care or service you already received.

 

The following are examples of requests for initial determinations:

• You ask us to pay for a prescription drug you have received.
• You ask for a Part D drug that is not on your plan sponsor'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

authorizations, dosage limits, quantity limits, or step therapy requirements. Requesting an exception to a utilization management tool is a type of formulary exception.

• 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 the cost of a drug you bought at an out-of-network

pharmacy. In certain circumstances, out-of-network purchases, including drugs provided to you in a physician’s office, will be covered by the Plan.

• You are not getting Part C medical care or services you want, and you believe that this care is covered by the Plan.
• We will not approve the medical treatment your doctor or other medical provider wants to give you, and you believe that this treatment is covered by the Plan.
• You are being told that a medical treatment or service you have been getting will be reduced or stopped, and you believe that this could harm your health.
• You have received Part C medical care or services that you believe should be covered by the Plan, but we have refused to pay for this care.

What is an exception?

 

An exception is a type of initial determination (also called a “coverage determination”) involving a Part D drug. You or your doctor may ask us to make an exception to our Part D coverage rules in a number of situations.

• You may ask us to cover your Part D drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan that covers those excluded drugs.
• You may ask us to waive coverage restrictions or limits on your Part D drug. For

example, for certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.

• You may ask us to provide a higher level of coverage for your Part D drug. If your Part D drug is contained in our non-preferred tier, you may ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the copayment amount you must pay for your Part D drug. Please note, if we grant your request to cover a Part D drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for Part D drugs that are in the specialty tier.

Generally, we will only approve your request for an exception if the alternative Part D drugs included on the Plan formulary or the Part D drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

 

Your doctor must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor should be sent to us with the exception request.

 

If we approve your exception request, our approval is valid for the remainder of the Plan year, so long as your doctor continues to prescribe the Part D drug for you and it continues to be safe for treating your condition. If we deny your exception request, you may appeal our decision.

 

Note: If we approve your exception request for a Part D non-formulary drug, you cannot request an exception to the co-payment or coinsurance amount we require you to pay for the drug.

 

Who may ask for an initial determination?

You, your prescribing physician, or someone you name may ask us for an initial determination. The person you name would be your “appointed representative.” You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under State law to act for you.  If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative.  You also have the right to have a lawyer act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. 

Both you and the person you have named, as an authorized representative will need to sign the representative form (see below). This completed form must be included with each grievance.

Appointment of Representation Form

 

Asking for a "standard" or "fast" initial determination

 

A decision about whether we will give you, or pay for, the Part D drug and/or Part C medical care or service you are requesting can be a "standard" decision that is made within the standard time frame, or it can be a "fast" decision that is made more quickly. A fast decision is also called an “expedited" decision.

 

Asking for a standard decision

 

To ask for a standard decision for a Part D drug and/or Part C medical care or service, you, your doctor, or your representative can call, fax, or write us at the numbers or address listed below:

 

Part D Coverage Determinations

 

Call:  1-888-505-1201, Monday - Sunday, 8am to 8pm, HST

(TTY/TDD user:  1-877-247-6272)

Fax:  1-866-388-1767

Write:  Pharmacy Department, P.O. Box 31577, Tampa, FL  33631-3577

 

 

Part C Organization Determinations

 

Call:  1-888-505-1201, Monday - Sunday, 8am to 8pm, HST

(TTY/TDD user:  1-877-247-6272)

Fax:  1-813-262-2802

Write:  P.O. Box 31370, Tampa, FL  33631

 

The forms below can be used to request a standard decision concerning a Part D prescription drug.  These forms may be faxed or mailed to us.

 

 

WellCare Injectable Infusion Form

 

Medicare Part D Coverage Determination Request Form

 

Medicare Prescription Drug Determination Request Form

Asking for a fast decision

 

You may ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. (Fast decisions apply only to requests for benefits that you have not yet received. You cannot get a fast decision if you are asking us to pay you back for a benefit that you already received.)  If you are requesting a Part D drug and/or Part C medical care or service that you have not yet received, you, your doctor, or your representative may ask us to give you a fast decision by calling, faxing, or writing us at the numbers or address listed below:

 

 

Part D Coverage Determinations

 

Call:  1-888-505-1201, Monday - Sunday, 8am to 8pm, HST

(TTY/TDD user:  1-877-247-6272)

Fax:  1-866-388-1767

Write:  Pharmacy Department, P.O. Box 31577, Tampa, FL  33631-3577

 

 

Part C Organization Determinations

 

Call:  1-888-505-1201, Monday - Sunday, 8am to 8pm, HST

(TTY/TDD user:  1-877-247-6272)

Fax:  1-813-262-2802

Write:  P.O. Box 31370, Tampa, FL  33631

 

 

The forms below can be used to request a fast decision concerning a Part D drug.  These forms may be faxed or mailed us.

 

 

WellCare Injectable Infusion Form

 

Medicare Part D Coverage Determination Request Form

 

Medicare Prescription Drug Determination Request Form

 

Be sure to ask for a “fast” or “expedited” review. If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.

 

If you ask for a fast decision without support from a doctor, we will decide if your healthrequires a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a “fast grievance.” You have the right to file a fast grievance if you disagree with our decision to deny your request for a fast review.  If we deny your request for a fast initial determination, we will give you a standard decision.

 

What happens when you request an initial determination?

• For a standard initial determination about a Part D drug (including a request to pay you back for a Part D drug that you have already received). 

Generally, we must give you our decision no later than 72 hours after we receive your request, but we will make it sooner if your request is for a Part D drug that you have not received yet and your health condition requires us to. However, if your request involves a request for an exception (including a formulary exception, tiering exception, or an exception from utilization management rules – such as prior authorization), we must give you our decision no later than 72 hours after we receive your physician's "supporting statement" explaining why the drug you are asking for is medically necessary.

If you have not received an answer from us within 72 hours after we receive your request (or your physician's supporting statement if your request involves an exception), your request will automatically go to Appeal Level 2.

• For a fast initial determination about a Part D drug that you have not yet received.

If we give you a fast review, we will give you our decision within 24 hours after you or your doctor ask for a fast review. We will give you the decision sooner if your health condition requires us to. If your request involves a request for an exception, we will give you our decision no later than 24 hours after we have received your physician's "supporting statement," which explains why the drug you are asking for is medically necessary. 

If we decide you are eligible for a fast review and you have not received an answer from us within 24 hours after receiving your request (or your physician's supporting statement if your request involves an exception), your request will automatically go to Appeal Level 2.

• For a decision about payment for Part C medical care or services you already received. 

If we do not need more information to make a decision, we have up to 30 days to make a decision after we receive your request, although a small number of decisions may take longer. However, if we need more information in order to make a decision, we have up to 60 days from the date of the receipt of your request to make a decision. You will be told in writing when we make a decision. 

If you have not received an answer from us within 60 days of your request, you have the right to appeal.

• For a standard decision about Part C medical care or services you have not yet received. 

We have 14 days to make a decision after we receive your request. However, we can take up to 14 more days if you ask for additional time, or if we need more information (such as medical records) that may benefit you. If we take additional days, we will notify you in writing. If you believe that we should not take additional days, you can make a specific type of complaint called a “fast grievance”.  

If you have not received an answer from us within 14 days of your request (or by the end of any extended time period), you have the right to appeal.

• For a fast decision about Part C medical care or services you have not yet received. 

If you receive a “fast” decision, we will give you our decision about your requested medical care or services within 72 hours after we receive the request. However, we can take up to 14 more days if we find that some information is missing that may benefit you, or if you need more time to prepare for this review. If we take additional days, we will notify you in writing. If you believe that we should not take any extra days, you can file a fast grievance. We will call you as soon as we make the decision. 

If we do not tell you about our decision within 72 hours (or by the end of any extended time period), you have the right to appeal. If we deny your request for a fast decision, you may file a "fast grievance."

What happens if we decide completely in your favor?

• For a standard decision about a Part D drug (including a request to pay you back for a Part D drug that you have already received). 

We must cover the Part D drug you requested as quickly as your health requires, but no later than 72 hours after we receive the request. If your request involves a request for an exception, we must cover the Part D drug you requested no later than 72 hours after we receive your physician's "supporting statement." If you are asking us to pay you back for a Part D drug that you already paid for and received, we must send payment to you no later than 30 calendar days after we receive the request (or supporting statement if your request involves an exception).

• For a fast decision about a Part D drug that you have not yet received. 

We must cover the Part D drug you requested no later than 24 hours after we receive your request. If your request involves a request for an exception, we must cover the Part D drug you requested no later than 24 hours after we receive your physician's "supporting statement."

• For a decision about payment for Part C medical care or services you already received.

Generally, we must send payment no later than 30 days after we receive your request, although a small number of decisions may take up to 60 days. If we need more information in order to make a decision, we have up to 60 days from the date of the receipt of your request to make payment.

• For a standard decision about Part C medical care or services you have not yet received.

We must authorize or provide your requested care within 14 days of receiving your request. If we extended the time needed to make our decision, we will authorize or provide your medical care before the extended time period expires. 

• For a fast decision about Part C medical care or services you have not yet received.

We must authorize or provide your requested care within 72 hours of receiving your request. If we extended the time needed to make our decision, we will authorize or provide your medical care before the extended time period expires.

 

What happens if we decide against you?

 

If we decide against you, we will send you a written decision explaining why we denied your request. If an initial determination does not give you all that you requested, you have the right to appeal the decision.

 

 

To learn more about the importance of reporting adverse events, product problems and product use errors, please visit FDA Medwatch Reporting. 

 

 

Appeal Level 1: Appeal to the Plan

 

You may ask us to review our initial determination, even if only part of our decision is not what you requested. An appeal to the plan about a Part D drug is also called a plan

"redetermination." An appeal to the plan about Part C medical care or services is also called a plan "reconsideration." When we receive your request to review the initial determination, we give the request to people at our organization who were not involved in making the initial determination. This helps ensure that we will give your request a fresh look.

Who may file your appeal of the initial determination?

If you are appealing an initial decision about a Part D drug, you or your representative may file a standard appeal request, or you, your representative, or your doctor may file a fast appeal request.  You can appoint any individual (such as a relative, friend, advocate, attorney, other) to act as your representative in the appeal process. Both you and the person you have named, as an authorized representative will need to sign the representative form (see below). This completed form must be included with each appeal.

Appointment of Representation Form

 

If you are appealing an initial decision about Part C medical care or services, the rules about who may file an appeal are the same as the rules about who may ask for an organization determination.

However, providers who do not have a contract with the Plan may also appeal a payment decision as long as the provider signs a “waiver of payment” statement saying it will not ask you to pay for the Part C medical care or service under review, regardless of the outcome of the appeal.

 

How soon must you file your appeal?

 

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How to file your appeal

 

1. Asking for a standard appeal

To ask for a standard appeal about a Part D drug and/or Part C medical care or service a signed, written appeal request must be sent to the address listed below:

 

Part D Appeals:

 

Call:  1-888-505-1201, Monday - Sunday, 8am to 8pm, HST

(TTY/TDD user:  1-877-247-6272)

Fax:  1-866-201-0657

Write:  Appeals Department, P.O. Box 31368, Tampa, FL  33631-3368

 

 

Part C Appeals:

 

Call:  1-888-505-1201, Monday - Sunday, 8am to 8pm, HST

(TTY/TDD user:  1-877-247-6272)

Fax:  1-866-201-0657

Write:  Appeals Department, P.O. Box 31368, Tampa, FL  33631-3368

 

 

You may also ask for a standard appeal by calling us at the phone number shown above.  

 

 

The forms below can be used to request a standard appeal for a Part D drug.  These forms can be faxed back to us.

 

WellCare Medicare Redetermination Request Form

 

WellCare Provider/Physician Appeal Form

 

2. Asking for a fast appeal

If you are appealing a decision we made about giving you a Part D drug and/or Part C medical care or service that you have not received yet, you and/or your doctor will need to decide if you need a fast appeal. The rules about asking for a fast appeal are the same as the rules about asking for a fast initial determination. You, your doctor, or your representative may ask us for a fast appeal by calling, faxing, or writing us at the numbers or address listed above. 

 

The forms below can be used to request a fast appeal for a Part D drug.  These forms can be faxed back to us.

 

WellCare Medicare Redetermination Request Form

 

WellCare Provider/Physician Appeal Form

 

If your request for a fast decision is made outside of regular weekday business hours, you must call Customer Service and make your request. Your request will be reviewed and a decision made within 72 hours of your request.

 

Be sure to ask for a "fast" or "expedited" review. Remember, if your doctor provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically give you a fast appeal.  If you ask for a fast decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a “fast grievance.” You have the right to file a fast grievance if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast appeal, we will give you a standard appeal. 

While the process for deciding on a standard or fast appeal is the same as the process at the initial determination level, the place where the appeal is sent is different.

 

Getting information to support your appeal

We must gather all the information we need to make a decision about your appeal. If we need your assistance in gathering this information, we will contact you or your representative. You have the right to obtain and include additional information as part of your appeal. For example, you may already have documents related to your request, or you may want to get your doctor’s records or opinion to help support your request. You may need to give the doctor a written request to get information.

 

You may give us your additional information to support your appeal by calling, faxing, orwriting us at the numbers or address listed above. 

 

You may also deliver additional information in person to the address listed above.

 

You also have the right to ask us for a copy of information regarding your appeal. You may call or write us at the phone number or address listed above.

 

We are allowed to charge a fee for copying and sending this information to you.

How soon must we decide on your appeal?

• For a standard decision about a Part D drug that includes a request to pay you back for a Part D drug you have already paid for and received. 

We will give you our decision within seven calendar days of receiving the appeal request.  We will give you the decision sooner if you have not received the drug yet and your health condition requires us to. If we do not give you our decision within seven calendar days, your request will automatically go to Appeal Level 2.

• For a fast decision about a Part D drug that you have not yet received. 

We will give you our decision within 72 hours after we receive the appeal request. We will give you the decision sooner if your health condition requires us to. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

• For a decision about payment for Part C medical care or services you already received. 

After we receive your appeal request, we have 60 days to decide. If we do not decide within 60 days, your appeal automatically goes to Appeal Level 2.

• For a standard decision about Part C medical care or services you have not yet received. 

After we receive your appeal, we have 30 days to decide, but will decide sooner if your health condition requires. However, if you ask for more time, or if we find that helpful information is missing, we can take up to 14 more days to make our decision. If we do not tell you our decision within 30 days (or by the end of the extended time period), your request will automatically go to Appeal Level 2.

• For a fast decision about Part C medical care or services you have not yet received.  

After we receive your appeal, we have 72 hours to decide, but will decide sooner if your health condition requires. However, if you ask for more time, or if we find that helpful information is missing, we can take up to 14 more days to make our decision. If we do not decide within 72 hours (or by the end of the extended time period), your request will automatically go to Appeal Level 2.

 

What happens if we decide completely in your favor?

• For a standard decision about a Part D drug (including a request to pay you back for a Part D drug that you have already received).

We must cover the Part D drug you requested as quickly as your health requires, but no later than 7 calendar days after we receive the request. If you are asking us to pay you back for a Part D drug that you already paid for and received, we must send payment to you no later than 30 calendar days after we receive the request.

• For a fast decision about a Part D drug that you have not yet received.

We must cover the Part D drug you requested no later than 72 hours after we receive your request.

• For a decision about payment for Part C medical care or services you already received.

We must pay within 60 days of receiving your appeal request.

• For a standard decision about Part C medical care or services you have not yet received.

We must authorize or provide your requested care within 30 days of receiving your appeal request. If we extended the time needed to decide your appeal, we will authorize or provide your requested care before the extended time period expires.

• For a fast decision about Part C medical care or services you have not yet received.

We must authorize or provide your requested care within 72 hours of receiving your appeal request. If we extended the time needed to decide your appeal, we will authorize or provide your requested care before the extended time period expires.

 

Please click here to access the Evidence of Coverage for more detailed information on all appeals and grievance policies.

 

Appeal Level 2: Independent Review Entity (IRE)

 

At the second level of appeal, your appeal is reviewed by an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this entity. We are allowed to charge a fee for copying and sending this information to you.

How to file your IRE appeal

If you asked for Part D drugs or payment for Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the IRE. If you choose to appeal, you must send the appeal request to the IRE. The decision you receive from the plan (Appeal Level 1) will tell you how to file this appeal, including who can file the appeal and how soon it must be filed. 

 

If you asked for Part C medical care or services, or payment for Part C medical care or services, and we did not rule completely in your favor at Appeal Level 1, your appeal is automatically sent to the IRE.

 

Please click here to access the Evidence of Coverage for more detailed information on all appeals and grievance policies.

Grievances

A grievance is any complaint or dispute or an expression of dissatisfaction, other than one that involves a coverage determination, with any aspect of the operations, activities, or behavior of WellCare.

You can appoint any individual (such as a relative, friend, advocate, attorney, other) to act as your representative in the grievance process. Both you and the person you have named, as an authorized representative will need to sign the representative form (see below). This completed form must be included with each grievance.

Appointment of Representation Form

 

If you have concerns or problems related to your prescription drug coverage, we encourage you to contact us.  We will try to resolve any complaint over the phone.  If you would like to file a grievance, you can contact us by calling, faxing, or writing us at the numbers or address listed below:

 

Part D Grievances:

 

Call:  1-888-505-1201, Monday - Sunday, 8am to 8pm, HST

(TTY/TDD user:  1-877-247-6272)

Fax:  1-866-388-1769

Write:  Grievance Department, P.O. Box 31384, Tampa, FL  33631-3384

 

 

Part C Grievances:

 

Call:  1-888-505-1201, Monday - Sunday, 8am to 8pm, HST

(TTY/TDD user:  1-877-247-6272)

Fax:  1-866-388-1769

Write:  Grievance Department, P.O. Box 31384, Tampa, FL  33631-3384

 

We will notify you of a decision within 30 days of receipt of the written grievance. We may extend this time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.  An expedited grievance can be made orally by calling Customer Service listed at the number on the top of this page. 

 

Please click here to access the Evidence of Coverage for more detailed information on all appeals and grievance policies. 

If you would like to obtain a total number of grievances, appeals, and exceptions filed with the Plan, please call Customer Service listed at the number on the top of this page.

Rights and Responsibilities upon Disenrollment

If a beneficiary disenrolls, he/she should remember the following during the disenrollment process:  

• Use your WellCare prescription drug coverage and our network pharmacies to fill your prescriptions until your coverage ends. 
• If you leave WellCare, you can join another Medicare PDP or a Medicare Advantage plan as long as this type of plan is available in your area, they are accepting new members, and you meet the eligibility requirements of the plan. 
• You may only disenroll or switch plans during certain periods. 

 WellCare can disenroll a beneficiary in the following circumstances:

• You are no longer eligible for Medicare prescription drug coverage. 
• If WellCare is no longer contracting with Medicare or leaves your service area. 
• When you move out of WellCare's service area. 
• You materially misrepresent a 3rd party reimbursement. 
• You fail to pay premium.
• You engage in disruptive behavior, provided fraudulent information when you enrolled or abuse your enrollment card. 

Please access the Evidence of Coverage for more detailed information on all Member Rights and Responsibilities including disenrollment situations and procedures.

 

Last modified: 11/21/2008