Medicare Grievances (Complaints) and Appeals

A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or Part B drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay. 

If you or your doctor are not sure if a service, item, or Part B drug is covered by Virginia Premier, either of you can ask for a coverage decision before the doctor gives the service, item, or Part B drug. Sometimes a coverage decision is also called an organization determination.

How can I file a coverage decision to get a medical, behavioral health or long-term care service or Part B drug?

To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a decision.

• You can call us at: 1-877-739-1370 (TTY:711) OR
• You can write to us at:
  Express Scripts
  Attn: Medicare Reviews
  P.O. box 66571
  St. Louis, MO 63166-6571

How long does it take to get a coverage decision?

Once we receive your request, it usually takes up to 14 calendar days after you asked. If we don’t give you our decision within 14 calendar days, you can appeal. Making an appeal means asking us to review our decision. Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days.

Can I get a coverage decision faster?

Yes. If you need a response faster because of your health, you should ask us to make a “fast coverage decision.” If we approve the request, we will notify you of our decision within 72 hours.

Asking for a fast coverage decision:

If you request a fast coverage decision, start by calling, writing, or faxing our plan to ask us to cover the care you want. You can call us at 1-877-739-1370 (TTY: 711). You can also have your doctor or your representative call us.

You must meet the following two requirements to get a fast coverage decision:

• If you are asking for coverage for medical care or an item you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care or an item you have already received.)
• If the standard 14-day deadline could cause serious harm to your health or hurt your ability to function

If your doctor says that you need a fast coverage decision, we will automatically give you one.

If you ask for a fast coverage decision, without your doctor’s support, we will decide if you get a fast coverage decision. Please see your plan’s Evidence of Coverage for additional information.

If the coverage decision is Yes, when will I get the service or item?

You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period.

If the coverage decision is No, how will I find out?

If the answer is No, we will send you a letter telling you our reasons for saying no. If we say no, you have the right to ask us to reconsider – and change – this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage. If you decide to make an appeal, it means you are going on to Level 1 of the appeals proces

A Coverage Determination is a decision about whether a Part D drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. For more information, check your plan’s Evidence of Coverage.

A member, member representative or prescribing physician can request to initiate a coverage determination. You can request it by either:

• Phone: 1-877-739-1370 (TTY: 711)
• Mail:
  Express Scripts
  Attn: Medicare Reviews
  P.O. Box 66571
  St. Louis, MO 63166-6571
• Completing the online Prior Authorization (coverage determination) form at PromptPA

If your coverage determination is denied for your Part D drug, you may request a redetermination. Visit your plan’s Evidence of Coverage for more information.

How long does it take to get a coverage decision for Part D drugs?

We will give you an answer on a standard coverage decision within 72 hours. We will give you an answer on reimbursing you for a Part D drug you already paid for within 14 calendar days.

• If you are asking for an exception, include the supporting statement from the doctor or other prescriber.
• You or your doctor or other prescriber may ask for a fast decision. (Fast decisions usually come within 24 hours.) Please check your plan’s Evidence of Coverage for more information

An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. For example, we might decide that a service, item, or Part D drug that you want is not covered or is no longer covered by Virginia Premier. If you or your doctor disagree with our decision, you can appeal.

How do I file an appeal? 

To start your appeal, you, your doctor or another provider, or your representative must contact us in writing or by phone.

• You can submit a written request to the following address:
  Express Scripts
  Attn: Medicare Appeals
  P.O. Box 66588
  St. Louis, MO 63166-6588
• Or by faxing a written request to: 1-877-852-4070

• Express Scripts Help Desk at 1-800-927-6048 Calls to this number are free. We are available 24 hours a day, 7 days a week.

Can someone else make the appeal for me?

Yes. Your doctor or another provider can make the appeal for you. Also, someone besides your doctor or another provider can make the appeal for you, but first you must complete an Appointment of Representative form. The form gives the other person permission to act for you. You can download an Appointment of Representative form, call Member Services and ask for one, or visit the Medicare website. The form will give the person permission to act for you. You must give us a copy of the signed form. If the appeal comes from someone besides you or your doctor or another provider, we must receive the completed Appointment of Representative form before we can review the appeal.

How much time do I have to make an appeal?

You must ask for an appeal within 60 calendar days from the date of the letter we sent to tell you our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of a good reason are: you had a serious illness, or we gave you the wrong information about the deadline for requesting an appeal.

Can my doctor give you more information about my appeal?

Yes, you and your doctor may give us more information to support your appeal.
When will I hear about a “standard” appeal decision?

If your appeal is about:

• A Part D drug — You’ll get a decision in 7 calendar days.
• A non-Part D drug or a Medicare-covered service – You’ll get a decision in 30 calendar days. We can also take up to 14 extra calendar days if we need more information.

When will I hear about a “fast” appeal decision?

If your appeal is about:

• A Part D drug — You’ll get a decision in 24 hours.
• A non-Part D drug or a Medicare-covered service – You’ll get a decision in 72 hours. We will give you our answer sooner if your health requires us to do so. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter.

If our answer is yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal.

If our answer is no to part or all of what you asked for, we will send you a letter. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens. You can see your plan’s Evidence of Coverage for more information.

How can I get an aggregate number of grievances, appeals, and exceptions filed with Virginia Premier?

Please call us at 1-877-739-1370 (TTY: 711)..

A grievance is a complaint and does not involve a request for payment, a request for authorization for services or a request for an appeal of denied services by Virginia Premier. For example, you would file a grievance if: 

• You are unhappy with the quality of care, such as the care you got in the hospital.
• You think that someone did not respect your right to privacy or shared information about you that is confidential.
• A health care provider or staff was rude or disrespectful to you.
• Virginia Premier staff treated you poorly.
• You think you are being pushed out of the plan.
• You cannot physically access the health care services and facilities in a doctor or provider’s office.
• You are having trouble getting an appointment, or waiting too long to get it.
• You think the clinic, hospital or doctor’s office is not clean
• Your doctor or provider does not provide you with an interpreter during your appointment.
• You think we failed to give you a notice or letter that you should have received.
• You believe that we are not meeting our deadlines for making a coverage decision or answering your appeal.

How to file a complaint (grievance)

Call Member Services at 1-877-739-1370 (TTY: 711). The complaint must be made within 60 calendar days after you had the problem you want to complain about. If there is anything else you need to do, Member Services will tell you.

• You can also write your complaint and send it to us. If you put your complaint in writing, we will respond to your complaint in writing:
  Express Scripts
  Attn: Medicare Appeals
  P.O. Box 66588
  St. Louis, MO 63166-6588
• Grievances and Appeals Fax Number: 1-877-852-4070

If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast complaint” and respond to your complaint within 24 hours.

If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.

• Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest, or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint
• If we do not agree with some or all of your complaint we will tell you and give you our reasons. We will respond whether we agree with the complaint or not.

You can also send your complaint to Medicare. Medicare takes your complaints seriously and will use this information to help improve the quality of the of the Medicare program. Please feel free to call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. The call is free. In lieu of calling, you can also find the Medicare Complaint Form online.Call Member Services at 1-877-739-1370 (TTY: 711). The complaint must be made within 60 calendar days after you had the problem you want to complain about. If there is anything else you need to do, Member Services will tell you.

• You can call us at Member Services at 1-877-739-1370 (TTY: 711).
• Call the Office of the Managed Care Ombudsman for free help. The Office of the Managed Care Ombudsman helps people enrolled in a managed care health plan. The phone number is 1-877-310-6560.
• Call the Office of the State Long-Term Care Ombudsman for free help. The Office of the State Long-Term Care Ombudsman helps people receiving long-term care services. The phone number is 1-800-552-3402.
• Call the Medicare Ombudsman at 1-800-MEDICARE or visit the website.
• Call the Virginia Insurance Counseling and Assistance Program (VICAP) for free help. The VICAP is an independent organization. It is not connected with this plan. The phone number is 1-800-552-3402.
• If you feel you have used all your options with us, you may submit a Medicare complaint form on the Medicare website .
• Talk to your doctor or another provider. Your doctor or another provider can ask for a coverage decision or appeal on your behalf.
• Talk to a friend or family member and ask him or her to act for you. You can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal. If you want a friend, relative, or another person to be your representative, you can get the form on the Medicare website. The form will give the person permission to act for you. You must give us a copy of the signed form.
• You also have the right to ask a lawyer to act for you. You may call your own lawyer, or get the name of a lawyer from the local bar association or another referral service. Some legal groups will give you free legal services if you qualify. If you want a lawyer to represent you, you will need to fill out the Appointment of Representative form. However, you do not have to have a lawyer to ask for any kind of coverage decision or to make an appeal.