You may ask us to review our coverage determination (Part D) or organization determination (Part C), even if only part of our decision is not what you requested. An appeal to our plan about a Part D drug is also called a plan “Redetermination.” An appeal about a medical care decision is called a plan “Reconsideration.” When we review your appeal, we look carefully at the information about your request for an exception to Part D coverage rules or for coverage of medical care to ensure we were fair and that we followed all applicable rules when we made our initial decision.
When you appeal a coverage determination about a Part D drug or an organization determination for Part C medical care or services, you, your representative, or your doctor may file a standard appeal request or a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within 60 days from the date included on the notice of our coverage determination or organization determination. We may give you more time if you have a good reason (also known as Good Cause) for missing the deadline
To ask for a “standard” or “fast” appeal for a Part D drug or Part C medical care or services, you, your doctor or your representative should use the following contact information:
For Part C Appeals (about your medical care services):
Mailing Address:
Gold Kidney Health Plan Inc.
Attention: Utilization Management Dept.
P.O. Box 285
Portsmouth, NH 03802
Phone: 1-844-294-6535
TYY Users: 711
Fax: 1-866-515-7869 Attention: Gold Kidney Appeals & Grievances Department
If you are appealing a decision we made about giving you a Part D drug or Part C medical care or services you have not received yet, you and/or your doctor will need to decide if you need a fast (or “expedited”) appeal. The requirements for receiving a fast appeal are the same as those for receiving a fast coverage decision. If your doctor provides a written or oral statement explaining your need for a fast appeal, we will automatically give you one.
For Part C and Part D fast appeals, we must give you our decision within 72 hours after receiving your appeal. For Part C appeals only, we may take up to 14 more days if you request more time or if we need more information to make our decision. If we do not meet these guidelines, we must send your appeal to Appeal Level 2. To request a fast appeal outside of regular business hours, please fax your request to the fax numbers shown in the “Asking for a standard appeal” section above.
For Part D Appeals (about Part D prescription drugs):
Mailing Address:
MedImpact
Attention: Appeals & Grievances Dept.
10181 Scripps Gateway Court
San Diego, CA 92131
Phone: 888-672-7206
Fax: 858-790-6060
Webpage: https://mp.medimpact.com/partdappeal
For standard Part D appeals, we must inform you of our decision within 7 days after receiving your appeal (sooner if your health requires a faster decision). If we fail to do so, we must send your appeal to Level 2 in the appeals process.
For fast and standard Part D appeals, if we deny your Level 1 appeal to our plan, you may choose to accept the denial, or you may make another appeal. This appeal would be a Level 2 appeal. At this level, an outside Independent Review Organization with no connection to our plan reviews our decision and decides whether to uphold it or change it.
Provided you meet certain rules, you may be able to continue up to 5 levels of appeal. Please see our plan’s Evidence of Coverage for more information about these additional appeal levels. You also have appeal rights if you believe you are being released from a hospital too soon or you believe coverage for home health, skilled nursing or outpatient rehabilitation care is ending too soon.
The Evidence of Coverage also has information about these types of appeals, so please consult your Evidence of Coverage or contact our Member Services Department at 1-844-294-6535, 8:00 A.M. – 5:00 P.M., Monday – Friday.
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