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Determinations, Appeals, and Grievances

For Medica Advantage Solution® (HMO-POS, PPO) and Medica Advantage℠ (PPO) Members

Do you have a concern?

If you have a concern with your Part D prescription drug coverage or Part C medical benefits, we encourage you to call our Member Services first. We'll do everything we can to resolve your concern over the phone.

  • Minnesota - 1-866-269-6804 (TTY: 711) toll-free
  •  Nebraska and Iowa - 1-866-398-7374 (TTY: 711) toll-free
  • North Dakota and South Dakota - 1-877-407-8494 (TTY: 711) toll-free
    8 a.m. - 9 p.m. CT, daily 

Mail:
Medica
P.O. Box 9310 CP520
Minneapolis, MN 55440


What if your concern isn't resolved?
If we can't resolve your concern over the phone, you may need to take extra steps. These include:

  • Determination – a request that we reconsider coverage
  • Appeal – a request that we reconsider a determination
  • Grievance – a formal complaint

Below, we'll walk you through how to complete these next steps.

See your disenrollment rights. 

Coverage determinations (Part D)

A coverage determination (Part D) is a request you submit to us that asks us to decide if a Part D drug prescribed for you can be covered by your plan —and/or if the amount you are required to pay is appropriate. You can also use this type of determination to ask for us to waive coverage restrictions.

Types of coverage determinations (Part D) include:

  • Formulary (drug list) exceptions
  • Prior authorization exceptions
  • Step therapy exceptions
  • Quantity limits exceptions
  • Tiering exceptions

You can submit a coverage determination (Part D) request online or by printing and returning a paper form:

Online Coverage Determination (Part D) Form

Paper Request for Medicare Prescription Drug Determination Form (PDF)

Appeal your determination
If your coverage determination request is denied, you have the right to file an appeal asking us to reconsider the initial denial. To start an appeal, you’ll need to submit a Medicare Part D Prescription Drug Denial Appeal Form (redetermination form). There are two ways to submit the form:

Online Medicare Coverage Redetermination Form

Paper Request for Redetermination of Medicare Prescription Drug Denial Form (PDF)

Organization Determination (Part C)

An organization determination (Part C) is a request you submit to us that asks us to decide if a Part C medical service is covered by your plan and/or if the amount you're required to pay is appropriate.

To initiate an organization determination (Part C) request, you'll need to contact our Member Services department via phone, fax or mail:

Member Services

  • Minnesota - 1-866-269-6804 (TTY: 711) toll-free
  •  Nebraska and Iowa - 1-866-398-7374 (TTY: 711) toll-free
  •  North Dakota and South Dakota - 1-877-407-8494 (TTY: 711) toll-free
    Fax: 952-992-3660

8 a.m. – 9 p.m. CT, seven days a week

Mail:
Medica
P.O. Box 9310 CP520
Minneapolis, MN 55440

Appeal your determination
If you submitted a coverage determination request and it was denied, you have the right to file an appeal asking us to reconsider the initial denial. To start an appeal, you'll need to submit a Medica Benefit Review or Appeal form (depending on your plan):

Paper Medica Advantage Solution and Medica Advantage Benefit Review form (DOC)

Grievances

A grievance is a formal complaint.  Grievances may include:

  • Quality of care
  • Wait times
  • Member services
  • Other concerns

Filing a grievance with us means that you want us to address your complaint. This isn’t part of the determination or appeals process; but you can submit a grievance along with a determination request or appeal and it won't affect the outcome.

To submit a grievance, download, fill out, and return our complaint form:

Paper Medica Advantage Solution and Medica Advantage Complaint Form (PDF)

You may also file a grievance directly with Medicare about your Medicare health plan or your Part D prescription coverage. Here's a link to the online complaint form:

Online Medicare.gov Complaint Form

Appoint a representative


You can authorize an individual to act on your behalf. Just download and complete the Appointment of Representative form below. Both you and your representative will need to sign the form. When it’s complete, you can submit it along with your determination, appeal, or grievance, or send it to the same location where you already sent your determination, appeal, or grievance.

Paper Appointment of Representative form (PDF)

Legal information about appeals + grievances

For detailed information on how to file a grievance, see chapter 9 in your Evidence of Coverage (EOC) document. If you don't have Part D coverage, please see chapter 7 of your EOC document.

To obtain a total number of grievances, appeals, and exceptions filed with the plan/Part D sponsor, contact our Member Services

Want to learn more about appeals and grievances from Medicare?
Get more information on Medicare.gov.

Want to learn more about drug appeals from Medicare?
Get more information on Medicare.gov.

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Last Updated: December 2023