Appeals Process

There is an appeals process for Part C and Part D benefits.

Part C Appeals Process

There are five levels of the appeal process.

Level 1

If we deny all or any part of your request to cover or pay for service, you or your appointed representative may ask us to reconsider or “appeal” our decision. There are two kinds of appeals that you can file.

  • Standard Appeal: You, your doctor or appointed representative may ask for a standard appeal about providing health care or payment for care. For a decision about payment for care you have received, Alliance CompleteCare will give you a decision no later than 60 days after we get your appeal. We may extend this time by up to 14 days if you request more time or if we need more information and taking more time benefits you.
    For a decision about health care, we will give you a decision within 30 calendar days, but will make it sooner if your health condition requires it. However, if we find that some information is missing that would benefit you, we can take up to 14 more days to make a decision.
  • Expedited (Fast) Appeal: You, any doctor, or your representative can ask us to give an expedited appeal. We will give you a decision about your care within 72 hours after you or your doctor asks for it--sooner if your health requires. 

Level 2

If we deny any part of your first appeal, your appeal goes onto Appeal Level 2 where an independent review entity (IRE) will review your case. The IRE has no connection to Alliance CompleteCare. We will tell you in writing that your appeal has been sent to the IRE for review.

Level 3

If the organization that reviews your case in Appeal Level 2 does not rule in your favor, you or your appointed representative may ask for a review by an administrative law judge (ALJ) in writing within 60 days after the date you were notified of the decision made at Appeal Level 2. The ALJ will not review your appeal if the dollar value of the care in dispute is less than $140.

Level 4

If you get a denial at Appeal Level 3, you or your appointed representative can request a review by filing a written request with the Medicare Appeals Council (MAC). The letter that you get from the administrative law judge will tell you how to contact the Council.

Level 5

To request a judicial review of your case, you must file a civil action in a United States District Appeals Court. The letter you get from Medicare Appeal Council in Appeal Level 4 will tell you how to request this review. The United States District Appeals Court judge’s decision is final and you may not take the appeal any further.

Part D Appeals Process

There are five levels of the appeal process for Part D.

Level 1

If we deny all or any part of your request for a prescription drug, you or your appointed representative may ask us to reconsider or “appeal” our decision. There are two kinds of appeals that you can file.

  • Standard Appeal: You, your doctor or appointed representative may ask for a standard appeal about covering a prescription drug. For standard appeals Alliance CompleteCare will give you a decision no later than 7 days after we get your appeal.
  • Expedited (Fast) Appeal: You, any doctor, or your representative can ask us to give an expedited appeal. We will give you a decision about your care within 72 hours after you or your doctor asks for it--sooner if your health requires.

Level 2

If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed. To make a Level 2 Appeal you must contact the Independent Review Organization and ask for a review of your case. If we say no to your Level 1 Appeal, the written notice we send you will include instruction on how to make a Level 2 Appeal with the Independent Review Organization. The IRE has no connection to Alliance CompleteCare.

Level 3

If the organization that reviews your case in Appeal Level 2 does not rule in your favor, and the dollar value of the drug you have appealed meets certain minimum levels, you or your appointed representative may ask for a review by an administrative law judge (ALJ) in writing within 60 days after the date you were notified of the decision made at Appeal Level 2.

Level 4

If you get a denial at Appeal Level 3, you or your appointed representative can request a review by filing a written request with the Medicare Appeals Council (MAC). The letter that you get from the administrative law judge will tell you how to contact the MAC.

Level 5

To request a judicial review of your case, you must file a civil action in an United States District Appeals Court. The letter you get from Medicare Appeal Council in Appeal Level 4 will tell you how to request this review. The United States District Appeals Court judge’s decision is final and you may not take the appeal any further.

Useful Resources

  • Coverage Determination Request Form in English  Spanish and Chinese is used when the member wants to submit a request to cover a prescription. 
  • There also is an online version of the Medicare Part D Coverage Determination Form for members. (When you click on this link, you will leave the Alliance CompleteCare website.)

Appointing a Representative

You may appoint a representative if you would like help with your appeal for Part C or Part D coverage by completing an Authorized Representative Form in English  Spanish  Chinese. A doctor may act as your appointed representative. For anyone other than a doctor, you must let us know in writing the name of your appointed representative.

Viewing Member Materials

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Last updated 02102014