Coverage Determination (exception), Appeal and Grievance Process


What to do if you have complaints about your (Part D) Prescription Drug or (Part C) Medical benefits

If you have a complaint, we encourage you to first call Customer Service at the number listed below. We will try to resolve any complaint that you might have over the phone. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints.

To file a formal complaint, you may do one of the following:

  • Request a Coverage Determination (Part D) – This is a request for a decision from your plan about whether a Part D drug prescribed for you is covered by the plan and/or the amount you are required to pay. You may also request that coverage restrictions be waived.
  • Request an Organization Determination (Part C) – This is a request for a decision from your plan about whether a Part C medical service is covered and/or the amount you are required to pay.
  • File an Appeal – This is a request to have your plan reconsider an initial determination.
  • File a Grievance – This is a complaint that you would like addressed by your plan (does not include a request for an initial determination or an appeal).

Contact us to complete any of the above actions:

Call
1-800-234-8755 or 952-992-2300.
TTY users, please call the National Relay Center at 1-800-855-2880.
8 a.m. - 8 p.m., 7 days a week.

Please note that access to a representative may be limited on weekends/holidays during certain times of the year.


Fax 952-992-3660

Email GPConsumerAffairs@medica.com or

Write to:
Medica Customer Service
Mail Route CP320
PO Box 9310
Minneapolis, MN 55440-9310


Medica Forms and Information

Click on your plan below for the Medica forms and the information you need to request a Coverage Determination, Organization Determination or to file an Appeal or Grievance.

Medica Advantage Solution

View chapter 9 of the Medica Advantage Solution Evidence of Coverage (pages 119-175) for information on how to file a complaint.

Form Type Form Usage Forms

Coverage Determination Form (Part D only)

Use this form when requesting a Coverage Determination, including Formulary Exceptions, Prior Authorization Exceptions, Step Therapy Exceptions, Quantity Limits Exceptions, Tiering Exceptions.

Part D Coverage Determination Form for Advantage Solution, Clear Solution, Complete Solution, DUAL Solution and Prime Solution 
(print version)

Part D Coverage Determination Form 
(web version)

Appeal Form
(Part D & Part C)

Use this appeal form if you have received a denial and wish to file an appeal.

Appeal Form for Advantage Solution, Clear Solution, Complete Solution and Prime Solution 
(print version)

Appeal Request
(email version)

Grievance Form
(Part D & Part C)

 Use this form if you have a complaint that does not involve a coverage determination, organization determination, or appeal.

Advantage Solution and Clear Solution

Appointment of Representative Form

Use this form when you need to authorize an individual to represent you.

Appointment of Representative Form

Medica Clear Solution

View chapter 9 of the Medica Clear Solution Evidence of Coverage (pages 139-192) for information on how to file a complaint.

Form Type Form Usage Forms

Coverage Determination Form (Part D only)

Use this form when requesting a Coverage Determination, including Formulary Exceptions, Prior Authorization Exceptions, Step Therapy Exceptions, Quantity Limits Exceptions, Tiering Exceptions.

Part D Coverage Determination Form for Advantage Solution, Clear Solution, Complete Solution, DUAL Solution and Prime Solution 
(print version)

Part D Coverage Determination Form 
(web version)

Appeal Form
(Part D & Part C)

Use this appeal form if you have received a denial and wish to file an appeal.

Appeal Form for Advantage Solution, Clear Solution, Complete Solution and Prime Solution
(print version)

Appeal Request
(email version)

Grievance Form
(Part D & Part C)

 Use this form if you have a complaint that does not involve a coverage determination, organization determination, or appeal.

Advantage Solution and Clear Solution

Appointment of Representative Form

Use this form when you need to authorize an individual to represent you.

Appointment of Representative Form

Medica Complete Solution

View chapter 9 of the Medica Complete Solution Evidence of Coverage (pages 139-198) for information on how to file a complaint.

Form Type Form Usage Forms

Coverage Determination Form (Part D only)

Use this form when requesting a Coverage Determination, including Formulary Exceptions, Prior Authorization Exceptions, Step Therapy Exceptions, Quantity Limits Exceptions, Tiering Exceptions.

Part D Coverage Determination Form for Advantage Solution, Clear Solution, Complete Solution, DUAL Solution and Prime Solution
(print version)

Part D Coverage Determination Form
(web version)

Appeal Form
(Part D & Part C)

Use this appeal form if you have received a denial and wish to file an appeal.

Appeal Form for Advantage Solution, Clear Solution, Complete Solution and Prime Solution
(print version)

Appeal Request.
(email version)

Grievance Form
(Part D & Part C)

 Use this form if you have a complaint that does not involve a coverage determination, organization determination, or appeal.

Complete Solution

Appointment of Representative Form

Use this form when you need to authorize an individual to represent you.

Appointment of Representative Form

Medica DUAL Solution

View chapter 9 of the Medica DUAL Solution Evidence of Coverage (pages 132-192) for information on how to file a complaint. 

Form Type Form Usage Forms

Coverage Determination Form (Part D only)

Use this form when requesting a Coverage Determination, including Formulary Exceptions, Prior Authorization Exceptions, Step Therapy Exceptions, Quantity Limits Exceptions, Tiering Exceptions.

Part D Coverage Determination Form for Advantage Solution, Clear Solution, Complete Solution, DUAL Solution and Prime Solution
(print version)

Part D Coverage Determination Form
(web version)

Appeal Form
(Part D & Part C)

Use this appeal form if you have received a denial and wish to file an appeal.

Appeal Form for DUAL Solution
(print version)

Appeal Request
(email version)

Grievance Form
(Part D & Part C)

 Use this form if you have a complaint that does not involve a coverage determination, organization determination, or appeal.

DUAL Solution

Appointment of Representative Form

Use this form when you need to authorize an individual to represent you.

Appointment of Representative Form

Medica Prime Solution

View chapter 9 of the Medica Prime Solution Evidence of Coverage (pages 137-193) for information on how to file a complaint.

Form Type Form Usage Forms

Coverage Determination Form (Part D only)

Use this form when requesting a Coverage Determination, including Formulary Exceptions, Prior Authorization Exceptions, Step Therapy Exceptions, Quantity Limits Exceptions, Tiering Exceptions.

Part D Coverage Determination Form for Advantage Solution, Clear Solution, Complete Solution, DUAL Solution and Prime Solution
(print version)

Part D Coverage Determination Form
(web version)

Appeal Form
(Part D & Part C)

Use this appeal form if you have received a denial and wish to file an appeal.

Appeal Form for Advantage Solution, Clear Solution, Complete Solution and Prime Solution
(print version)

Appeal Request
(email version)

Grievance Form
(Part D & Part C)

 Use this form if you have a complaint that does not involve a coverage determination, organization determination, or appeal.

Prime Solution

Appointment of Representative Form

Use this form when you need to authorize an individual to represent you.

Appointment of Representative Form


Call 1-800-234-8755 or 952-992-2300. TTY users, please call the National Relay Center at 1-800-855-2880. 8 a.m. - 8 p.m., 7 days a week.

Please note that access to a representative may be limited on weekends/holidays during certain times of the year.

Physician Questions

Call 1-800-458-5512.


Information regarding the number of exceptions, appeals and grievances

If you would like to obtain aggregate information, please contact Medica Customer Service at 1-800-234-8755 or 952-992-2300
 from 8 a.m. - 8 p.m., 7 days a week.

Please note that access to a representative may be limited on evenings and weekends during certain times of the year.


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H2410_H2450_H2458_H3283_H7526_2976 Pending CMS Approval (xx/xx/xxxx)
Last Updated: December 2011