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Determinations, Appeals and Grievances

For Medica Advantage 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 Medica Customer Service first. We'll do everything we can to resolve your concern over the phone.

Call 1-800-234-8755 (TTY: 711)

What if your concern isnt 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 reconsider 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:

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:



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 Medica Customer Service via phone, fax or mail.

Medica Customer Service
Phone: 1-800-234-8755
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 a Medica Benefit Review form:



Grievance

A grievance is a formal complaint. Grievances may include:

  • Quality of care
  • Waiting times
  • Customer 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:

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:



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.



Legal Information About Appeals and 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 Evidence of Coverage document.

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

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.



Medica is an HMO-POS and PPO plan with a Medicare contract.  Enrollment in Medica depends on contract renewal.

This information is not a complete description of benefits. Call Medica at 1-866-269-6804 (TTY: 711) for more information.


Last Updated: May 2019

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