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Determinations, Appeals and Grievances

For Medica DUAL Solution® 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 Member Services first. We'll do everything we can to resolve your concern over the phone.

Call toll-free 1-888-347-3630 (TTY: 711)

What if your concern isn't resolved?

If we can't resolve your concern over the phone, you may need to take additional steps. These next steps include:

  • Determinations – a request to Medica to consider coverage
  • Appeals – a request to Medica to reconsider a determination
  • Grievances – a complaint

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

Coverage Determination (Part D)


A Coverage Determination (Part D) 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 Coverage Determination (Part D) include:

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

You can submit a Coverage Determination (Part D) request either 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 Medica to reconsider the initial denial. To start an appeal, you will need to submit a Medicare Part D Prescription Drug Denial Appeal Form. There are two ways to submit this 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 Medica asking us to decide whether a Part C medical service is covered by your plan and/or if the amount you are required to pay is appropriate.

To initiate an Organization Determination (Part C) request, you will need to contact Member Services via phone, fax or mail.

Member Services

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

Fax: 952-992-3660

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 Medica to reconsider the initial denial. To start an appeal, you will need to submit an appeal form:

Paper Medica Appeal form (PDF)

Grievance

A grievance is a formal complaint. Grievances may include:

  • Quality of care
  • Waiting times
  • Member service

Other concerns

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

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

Paper Medica DUAL Solution Grievance Form (PDF)

You may also file a grievance directly with Medicare about your Medicare health plan or your Part D prescription coverage. They offer an online complaint form:

Online Medicare.gov 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 the form. When it is complete, you can submit it along with your determination, appeal or grievance or send it to the same the location where you already sent your determination, appeal or grievance.

Paper Appointment of Representative form (PDF)

Legal Information About Appeals and Grievances

For detailed information on how to file a grievance, see Chapter 9 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 to learn more about drug appeals from Medicare?
Get more information on Medicare.gov

Contact us

1-888-347-3630 (toll-free) (TTY: 711)

8 a.m. – 9 p.m., daily
Access to a representatives may be limited at times.


Mailing address:
Medica
P.O. Box 9310
Minneapolis, MN 55440

About your coverage


Plan documents

Plan materials order form

ID card order form

Determinations, appeals and grievances

Resources


Member rights and responsibilities

Limited English Proficiency (LEP) plan (PDF)

How to get the care you need (PDF)

MN Board on Aging

Older Minnesotans Know Your Rights

Medica DUAL Solution is a health plan that contracts with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. Enrollment in Medica DUAL Solution depends on contract renewal.

American Indians can continue to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral.


Last Updated: May 2022
H2458_1002298 Approved