Part D Exceptions and Appeals Information
We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage. Please call Member Services at 1-800-573-8597, TTY/TDD 1-866-573-8591. Our business hours are Monday – Sunday, 8 A.M. – 8 P.M., except holidays.
This section gives the rules for making complaints in different types of situations. A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint.
Table of Contents:
What is a coverage determination?
Prior Authorization Guidelines
Requesting a Coverage Determination
Appointing a representative
An enrollee may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as his or her representative and file an appeal, coverage determination or grievance on his or her behalf. To be appointed by an enrollee, both the enrollee making the appointment and the representative accepting the appointment must sign, date, and complete a representative form (for purposes of this section, “representative form” means a Form CMS-1696 Appointment of Representative or other conforming instrument).
What is a grievance?
A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with Southeast Community Care or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.
Filing a formal grievance
You or your authorized representative may file a formal grievance either verbally or in writing. Your verbal grievance request can be made by contacting Member Service at 1-800-573-8597 or TTY/TDD 1-866-573-8591, Monday – Sunday, 8 A.M. – 8 P.M., except holidays. Your written grievance request should be mailed to: 4101 Lake Boone Trail, Ste 118, Raleigh, North Carolina 27607 Attention: Appeals & Grievance Unit. You may also fax a written grievance request to: 1-877-307-1341.
Grievance process
You will receive an acknowledgement letter from Southeast Community Care within 5 calendar days of receiving your formal grievance request. You may be contacted by Southeast Community Care to obtain or verify pertinent facts regarding your case. We may extend our decision for up to 14 days if it is in your best interest, or if you request an extension. Southeast Community Care will notify you in writing of the decision regarding your case within 30 calendar days from the receipt of your grievance request.
Your grievance may be determined to be an expedited grievance, if your issue is related to clinical issues that are not appropriate for the appeals process, such as appointment waiting times, or availability of specialist, or any other situations where you have indicated a need for immediate attention and resolution of the issue is due to the emergent or urgent nature of your medical condition.
Expedited Grievance Request
If your grievance request is expedited, the Appeals and Grievance Unit will determine if resolution is needed within 24 or 72 hours. The Appeals & Grievance Unit will investigate your expedited grievance and develop your case for review within 12 hours for a 24 hour grievance or within 24 hours for a 72 hour review. An administrative decision and/or clinical decision is made within 8 hours for a 24 hour grievance or 36 hours for a 72 hour grievance.
For a 72 hour review, you will be notified in writing or by telephone of the decision within 72 hours of your grievance request. Southeast Community Care will also send you a follow-up letter within 5 calendar days. For a 24 hour review, you will be notified by telephone of the decision within 24 hours of your grievance request. Southeast Community Care will also send you a follow-up letter within 5 calendar days.
What is a coverage determination?
Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request.
Prior Authorization Guidelines
Certain drugs are subject to prior authorization for coverage. The information provided in the link below will help you understand the requirements for coverage of a selected group of formulary medications. This is not an inclusive list, as there may be several non-formulary drugs that are not represented. Please refer to the formulary list to see which drugs require prior authorization (PA). Prior Authorization Guidelines (click to download PDF).
Requesting a Coverage Determination
If your doctor or pharmacist tells you that Southeast Community Care will not cover a prescription drug, you should contact us and ask for a coverage determination. With this decision, we explain whether we will provide the prescription drug you are requesting or pay for a prescription drug you have already received. Your verbal coverage determination request can be made by contacting Member Service at 1-800-573-8597 or TTY/TDD 1-866-573-8591, Monday – Sunday, 8 A.M. – 8 P.M., except holidays for additional assistance. Your written coverage determination request should be mailed to: 4101 Lake Boone Trail, Ste 118, Raleigh, North Carolina 27607 Attention: Pharmacy Unit. You may also fax a written coverage determination request to: 1-877-307-1341. When submitting a written request, you have the option of completing a coverage determination request form (click to download PDF). Physicians may also submit an authorization request form (Click to download PDF) to the plan, in the manner described previously to request a prior authorization, other utilization management requirement or supporting statements for exception requests. Authorization requests can also be sent to the plan by the physicians using the plans AOS computer system.
NOTE: If you are asking for a formulary or tiering exception, your PRESCRIBING PHYSICIAN must provide a statement to support your request. You cannot ask for a tiering exception for a drug in the plan’s Specialty Tier. In addition, you cannot obtain a brand name drug at the copayment that applies to generic drugs.
A decision about whether we will cover a Part D prescription drug can be a “standard" coverage determination that is made within the standard timeframe (typically within 72 hours) or it can be a “fast" coverage determination that is made more quickly (typically within 24 hours). A fast decision is sometimes called an “expedited coverage determination.” You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. (Fast decisions apply only to requests for Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Part D drug that you already received.)
You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.
What is an appeal?
An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.
Filing a Formal Appeal
If you are unhappy with the coverage determination, you can ask for an appeal. The first level of appeal is called a redetermination. There are also four other levels of appeal that an enrollee may request. You need to file your appeal within 60 calendar days from the date included on the notice of our coverage determination. We can give you more time if you have a good reason for missing the deadline. To file a standard appeal, you can send the appeal to us in writing at Southeast Community Care, 4101 Lake Boone Trail, Ste 118, Raleigh, North Carolina 27607 , Attention: Appeals and Grievance Unit. You may also fax your appeal to 1-877-307-1341. Please contact Member Service at 1-800-573-8597 or TTY/TDD 1-866-573-8591, Monday – Sunday, 8 A.M. – 8 P.M., except holidays for additional assistance.
The rules about asking for a fast appeal are the same as the rules about asking for a fast coverage determination. You, your doctor, or your appointed representative can ask us to give a fast appeal (rather than a standard appeal) by calling us at 1-800-573-8597 Monday – Sunday, 8 A.M. – 8 P.M., except holidays (for TTY, call 1-866-573- 8591). Or, you can deliver a written request to Southeast Community Care 4101 Lake Boone Trail, Ste 118, Raleigh, North Carolina 27607 , or fax it to 1-877-307-1341. Call Southeast Community Care at 1-800- 573-8597 to deliver requests outside of regular weekday business hours. Be sure to ask for a “fast,” "expedited," or “72-hour” review. Remember, that if your prescribing physician provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically treat you as eligible for a fast appeal.
Appeal Process
For a standard decision about a Part D drug, which includes a request for reimbursement for a Part D drug you already paid for and received. After we receive your appeal, we have up to 7 calendar days to give you a decision, but will make it sooner if your health condition requires us to. If we do not give you our decision within 7 calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case. For a fast decision about a Part D drug that you have not received. After we receive your appeal, we have up to 72 hours to give you a decision, but will make it sooner if your health requires us to. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2, where an independent organization will review your case.
For a full explanation of grievance, coverage determination (including exceptions), and appeals processes for Part D please refer to the Evidence of Coverage (EOC), Section 12.
If you are a member or physician and have a questions regarding the grievance, coverage determination, and appeals processes for Part D or wish to inquire about the status of a coverage determination or appeal request, please contact us at 1-800-573-8597 Monday – Sunday, 8 A.M. – 8 P.M., except holidays (for TTY, call 1-866-573- 8591).
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