Determinations, Appeals, and Grievances

Do you have a concern?

If you have a concern with your Medicare Part D prescription drug coverage or your medical benefits, we encourage you to call our Member Services department first. The call is free, and we'll do everything we can to help.

Call 1-888-347-3630 (toll-free)     (TTY: 711)
8 a.m. – 9 p.m. CT, daily

What if your concern isn't resolved?

If we can't help you over the phone, you do have options. These next steps include:

• Coverage Determinations - request to consider coverage for a Medicare Part D prescription drug
• Coverage Decision - request to consider coverage for a medical benefit
• An appeal – a request to reconsider a coverage determination or coverage decision
• A grievance – a complaint

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

Coverage Determination - Medicare Part D prescriptions

A Coverage Determination is a request you submit to Medica, asking us to decide whether 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 coverage restrictions to be waived.

Types of Part D Coverage Determinations include:

• Formulary exceptions
• Prior authorization exceptions
• Step therapy exceptions
• Quantity limits exceptions
• Tiering exceptions

Submit a Part D Coverage Determination:

You can submit your Part D Determination by phone, online, or by printing and returning a paper form:

• Phone: 1-888-347-3630 (TTY: 711)

• Online: Request for Prescription Drug Coverage Determination - Online Form

• By mail: Request for Medicare Prescription Drug Determination Form (PDF)

Appeal your Part D Coverage Determination

If your coverage determination is denied, you have the right to file an appeal asking Medica to reconsider the initial denial. You can request your appeal by phone, online, or by printing and returning a paper form:

• Phone: 1-888-347-3630 (TTY: 711)

• Online: Request for Redetermination of Medicare prescription Drug Denial - Online Form

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

Appeal your Coverage Decision

If your coverage decision is denied, you have the right to file an appeal asking Medica to reconsider the initial denial. You can request your appeal by phone, online or by printing and returning a paper form:

• Phone: 1-888-347-3630 (TTY: 711)

• Online: Appeal Form - Online

• By mail: Medica D-SNP Appeal form (PDF) 

   

What if I disagree with the appeal decision?

If you disagree with the decision on the appeal, you may then file a State Appeal (Fair Hearing with the state). You must first receive a decision from Medica on the appeal before filing a State Appeal (Fair Hearing with the state. Or, if Medica doesn't respond to your appeal within 30 days or ask for an extension, you don't need to wait for our decision to file a State Appeal (Fair Hearing with the state).

How to file a State Appeal (Fair Hearing with the state)

To request a State Appeal (Fair Hearing with the state), you must contact the Minnesota Department of Human Services Appeals Division within 120 days of Medica's appeal decision.

A State Appeal (Fair Hearing with the state) includes a meeting with a Human Services judge, Medica, and you or your authorized representative. Your hearing will be held by telephone unless you ask for a face-to-face meeting.

A State Appeal (Fair Hearing with the state) must be submitted in writing by mail, fax, or it can be filed in person at the Appeals Division.

Minnesota Department of Human Services - Appeals Division

By mail:

P.O. Box 64941
St. Paul, MN 55164

In person:

444 Lafayette Road North
St. Paul, MN 55155

Phone:

1-800-657-3510 (TTY: 711)

Fax:

651-431-7523

Online:

Appeal to State Agency Form (PDF)

Appeal to State Agency - Online Form

Questions about State Appeals?

Call the Minnesota Department of Human Services - Appeals Division at 1-800-657-3510 (TTY: 711), or visit their website below:

Minnesota Department of Human Services - Appeals Division

Ombudsman office:

You may also contact the Ombudsman for Public Managed Health Care Programs about your appeal. They can be reached at 651-431-2660 or 1-800-657-3729  (TTY: 711).

Grievance

A grievance is a formal complaint. You may submit a grievance to us at any time.

Reasons for filing a grievance may include:

• Quality of care
• Failure to respect your rights
• Customer service
• Delay in treatment or referral
• Not responding to appeals or grievances in required time frames
• Other concerns

Filing a grievance with Medica means you would like us to address your complaint. This is not part of the coverage determination, coverage decision, or appeals process; but you can submit a grievance along with a coverage determination, coverage decision, or appeal and it will not affect the outcome.

How to submit a grievance to Medica

There are three ways to submit a grievance to Medica:

Phone: 1-888-347-3630 (TTY: 711)

Online: Submit a Grievance - Online Form

Paper: Medica D-SNP Grievance Form (PDF)

If your grievance is about our denial of an expedited appeal or a grievance about urgent health care issues, we will respond to you within 72 hours. Otherwise, we will contact you in writing within 10 calendar days to let you know we've received your complaint.

How long it takes to respond to your grievance depends on how you submit it (see below), but we may extend the time frame by up to 14 days if you request  the extension or we justify a need for additional information and the delay is in your best interest.

How to submit a grievance to the state of Minnesota

If you disagree with our decision on your grievance, you can file your complaint with the Minnesota Department of Health (MDH).

In writing

MDH Health Policy and Systems Compliance Monitoring Division Managed Care Systems
P.O. Box 64882
St. Paul, MN 55164

By phone:

Call 1-800-657-3916 (toll-free) or 651-201-5100  (TTY: 711)

Online:

File a complaint at the MDH website

How to submit a grievance to Medicare

You can send a complaint directly to Medicare by phone or online.

Phone: 1-800-MEDICARE (1-800-633-4227)  (TTY: 1-877-486-2048)
24 hours a day, 7 days a week

Online:
Medicare Complaint Form

Appoint a representative

You may authorize an individual to act on your behalf. Simply download and complete the Appointment of Representative form below. Both you and your representative will need to sign and 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.

Appointment of Representative Form (PDF)

Legal Information About Appeals and Grievances

For detailed information on how to file a grievance, see chapter nine in your Member Handbook

To obtain an aggregate number of grievances, appeals, and exceptions filed with the Plan/Part D Sponsor, please contact Member Services.

Would you like to learn more about appeals and grievances from Medicare?
Get more information on Medicare.gov

Would you like more information about drug appeals from Medicare?
Get more information on Medicare.gov