A coverage determination is a request by you, your doctor or an authorized representative for a prescription drug. This can be a request for prior authorization, a request for a drug that is not listed on our formulary, a request for a quantity of a drug greater than what we allow, a request for an exception to our step-therapy requirements, or a request to pay a lower cost share/copayment.
You may use the following forms for your convenience:
To file a request, you can:
Note: Please remember to include what drug you are requesting, what diagnosis you are requesting it for, any drugs you have tried that didn’t work, and supply all medical records that support your request.
You may use this form: Standard Redetermination Form, to file a Redetermination request.
To file a request, you can:
In all cases, please include the following information in the request:
If applying timeframe of the Standard Redetermination process would jeopardize the member’s health, life or ability to regain maximum function, an Expedited (fast) Redetermination may be requested. A request for Expedited Redetermination can be made by phone or in writing to Highmark Wholecare. If the member’s physician or other prescribers does not provide a statement (either verbally or in writing) supporting the need for an Expedited Redetermination, a Highmark Wholecare Medical Director will review the case to decide if an Expedited Redetermination is required. If the request for an Expedited Redetermination is granted, Highmark Wholecare will notify the member and prescribing physician or other provider of the decision within seventy-two (72) hours of receiving the request. If there is no supporting statement from the physician, and the Medical Director decides that an Expedited Redetermination is not needed, the request will be reviewed under the Standard Redetermination process. Refer to your Evidence of Coverage for further details on Part D Appeals and Grievance procedures.
To file a request, you can:
Some of our services may require prior authorization. This means your doctor must first ask us if we will cover the procedure and may be required to provide documentation showing that it is medically necessary for you to receive these services.
Note: To file a request for the following, please contact:
To file a request, for all others:
Note: Please remember to include what you are requesting and supply all medical records that support your request.
A grievance is any complaint, other than one that involves a request for an organization determination expressing dissatisfaction with any aspect of the operations, activities or behavior of Highmark Wholecare or with the quality of care or service received from a Highmark Wholecare provider, regardless of whether corrective action is requested.
A grievance may be filed by phone or in writing and must be filed no later than sixty (60) calendar days after the event or incident that precipitates the grievance. Highmark Wholecare reviews all grievances as quickly as a member’s health condition requires, but no later than thirty (30) calendar days from when the grievance is received.
Note: If you are a provider with an issue, you must contact provider services.
To file a request, you can:
If Highmark Wholecare denies all or part of a request for a service or payment of a service, member and/or his or her authorized representative, or the member’s treating physician may ask us to reconsider our decision. This is called an appeal or a request for Reconsideration.
If Highmark Wholecare denies a request for coverage of a medical service, in full or in part, the member or authorized representative or the member’s treating physician may ask Highmark Wholecare to review the denial by requesting a Reconsideration. A request for a Reconsideration can be made by phone or in writing to Highmark Wholecare. Except in the case of an extension of the filing time frame, the request for reconsideration must be filed within sixty (60) calendar days from the date of the notice of the organization determination. Highmark Wholecare will review a request for Standard Reconsiderations as quickly as the member’s health condition requires, but no later than thirty (30) calendar days from the date the request was received. If the Reconsideration is a request for payment of a service that has already been rendered, Highmark Wholecare must resolve the matter within sixty (60) calendar days of receiving the request.
If the Reconsideration decision is not entirely in the member’s favor, Highmark Wholecare will automatically forward the case file to the Independent Review Entity (IRE). The IRE will review the facts of the case and decide if Highmark Wholecare’s decision was correct. There are other appeal options that may be available after the IRE level of review, depending on the value of the services in dispute. Please refer to your Evidence of Coverage for further details.
To file a request, you can:
If applying timeframe of the Standard Reconsideration process would jeopardize the member’s health, life or ability to regain maximum function, an Expedited (fast) Reconsideration may be requested. A request for Expedited Reconsideration can be made by phone or in writing to Highmark Wholecare. If the member’s treating physician does not provide a statement (either verbally or in writing) supporting the need for an Expedited Reconsideration, a Highmark Wholecare Medical Director will review the case to decide if an Expedited Reconsideration is required. If the request for an Expedited Reconsideration is granted, Highmark Wholecare will notify the member and the treating physician of the decision within seventy-two (72) hours of receiving the request. If there is no supporting statement from the physician, and the Medical Director decides that an Expedited Reconsideration is not needed, the request will be reviewed under the Standard Reconsideration process. Refer to your Evidence of Coverage for further details.
To file a request, you can:
A grievance is any complaint or dispute, other than one that involves a request for coverage, expressing dissatisfaction with the operations, activities or behavior of Highmark Wholecare including its vendors or with the quality of care or service received from a Highmark Wholecare Medicare Assured® provider even if you don’t want us to take action against the provider.
A grievance may be filed by a member and/or his or her authorized representative by phone or in writing and must be filed no later than sixty (60) calendar days after the event or incident that precipitates the grievance (causes you to be unhappy). A Highmark Wholecare employee reviews all grievances as quickly as a member’s health condition requires, but no later than thirty (30) days from when the grievance is received.
Note: If you are a provider with an issue, you must contact provider services.
To file a complaint/grievance:
An appeal refers to any of the procedures that deal with the review of adverse coverage determinations (meaning where we denied coverage) made by Highmark Wholecare regarding the benefits under a Part D plan that a member or their prescriber believes that he or she is entitled to receive. An appeal can also be filed to dispute any amounts a member must pay for drug coverage. Except when the time filing time frame is extended, the request must be filed within sixty (60) calendar days from the date of the notice of the Coverage Determination. These procedures are called Redeterminations by Highmark Wholecare and Reconsiderations at the Independent Review Entity (IRE), Administrative Law Judge (ALJ), Medicare Appeals Council (MAC) or judicial review levels of review.
If Highmark Wholecare denies a request for coverage of a Part D drug, in full or in part, the member and/or authorized representative or physicians and other prescribers (upon providing notice to the member) may ask Highmark Wholecare to review the denial by requesting a Redetermination (Appeal). A request for a Redetermination (Appeal) can be made by phone or in writing to Highmark Wholecare. Highmark Wholecare will review a request for Standard Redetermination as quickly as the member’s health condition requires, but no later than seven (7) calendar days from the date the request was received. If the Redetermination decision is not entirely in the member’s favor, the decision notice will explain the member’s right to request the review by the Independent Review Entity (IRE). The IRE will review the facts of the case and decide if Highmark Wholecare’s decision was correct. There are other appeal options that may be available after the IRE level of review, depending on the value of the drug in dispute.
You are now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the link: Medicare Complaint FormThe Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program. If you have any other feedback or concerns, or if this is an urgent matter, please call 1-800-MEDICARE (1-800-633-4227). TTY/TTD users can call 1-877-486-2048.
To file a request, you can:
In all cases, please include the following information in the request:
If applying timeframe of the Standard Redetermination process (7 days) would jeopardize the member’s health, life or ability to regain maximum function, an Expedited (fast) Redetermination may be requested. A request for Expedited Redetermination can be made by phone or in writing to Highmark Wholecare. If the member’s physician or other prescribers does not provide a statement (either verbally or in writing) supporting the need for an Expedited Redetermination, a Highmark Wholecare Medical Director will review the case to decide if an Expedited Redetermination is required. If the request for an Expedited Redetermination is granted, Highmark Wholecare will notify the member and prescribing physician or other provider of the decision within seventy-two (72) hours of receiving the request. If there is no supporting statement from the physician, and the Medical Director decides that an Expedited Redetermination is not needed, the request will be reviewed under the Standard Redetermination process. Refer to your Evidence of Coverage for further details on Part D Appeals and Grievance procedures.
To file a request, you can:
There are two types of Provider Appeals.
Provider Disputes are requests that are not regarding medical necessity rather are administrative in nature such as, but not limited to, disputes regarding the amount paid, appeals of denials regarding lack of modifiers, refunded claim payments due to incorrect payment or coordination of benefit issues.
Clinical Provider Appeals are cases that are denied due to lack of prior authorization or denied based on medical necessity.
To submit a Provider Dispute, please use this contact information below.
To submit a Clinical Provider Appeal, please use this contact information below.
NOTE: If you are a non-participating provider submitting a Medicare Claim/Post Service appeal, you must submit a Waiver of Liability form: Wavier of Liability in accordance with Medicare Law for your appeal to be considered. We have attached one for your convenience for submission with your appeal.
Members may name a relative, friend, advocate, or someone else to act on his or her behalf. This process is called Appointing a Representative.
Other persons may already be authorized under state law to act on a member’s behalf. In order to appoint another individual to act on a member’s behalf, both the member and the designated individual must sign and date a statement that gives this person legal permission to act as an Appointed Representative.
To appoint a representative, you may use this form: Appointment of Representative Form
You are now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the link: Medicare Complaint FormThe Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program. If you have any other feedback or concerns, or if this is an urgent matter, please call 1-800-MEDICARE (1-800-633-4227). TTY/TTD users can call 1-877-486-2048.
Health benefits or health benefit administration may be provided by or through Highmark Wholecare, an independent licensee of the Blue Cross Blue Shield Association (“Highmark Wholecare”). Highmark Wholecare offers HMO plans with a Medicare Contract. Enrollment in these plans depends on contract renewal.
Medicare Ombudsman Website
Best Available Evidence
Y0097_1359_2023_D
