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Determinations, Grievances, and Appeals

 

Information on how to obtain aggregate numbers of Grievances, Coverage Determinations, Appeals and Exceptions

 As a Medicare Advantage Organization, HealthSun Health Plans must disclose grievances, coverage determinations, appeals and exceptions data, upon request, to individuals eligible to elect a Medicare Advantage organization. By appeals data we mean all appeals filed with HealthSun Health Plans that are accepted for review, or withdrawn upon the member’s request, but excludes appeals that HealthSun Health Plans forwards to CMS’ Independent Review Entity (IRE) for dismissal.

Call our Member Services Department if you have any questions at 1-877-336-2069 (TTY: 1-877-206-0500).  

Appointment of Representative (AOR)

CMS Appointment of Representation Form

Medicare allows a beneficiary to appoint any individual (such as a relative, friend, advocate, physician, or an attorney) to act on his or her behalf as a representative in the grievances, coverage decisions and/or appeals process. The beneficiary making the appointment and the representative accepting the appointment must sign, date, and complete the Appointment of Representative Form. The appointment is valid for one year from the date the form is signed. 

Procedural Information

Request a Coverage Decision or an Exception

For more information, please see Chapter 9 in your plan's Evidence of Coverage (EOC).

A coverage decision about your benefits and coverage or about the amount we will pay for your medical services and prescription drugs.

An exception to cover a drug that is not covered in the way you would like it to be covered; such as to remove a coverage restriction, lower cost-sharing level, or cover a drug that is not on our Formulary.

You can call a HealthSun Member Service Representative or you can send your request in writing to our main office. The request must be made by you, your physician, or your appointed representative.

The exception request must include a supporting statement. Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. 

Medical Coverage:

Member Services Phone: 1-877-336-2069 (TTY: 1-877-206-0500)

Fax: 305-448-5783

Mailing: 3250 Mary Street Suite 400, Coconut Grove, FL 33133

Part D & Part B Drugs:

Member Services Phone: 1-877-336-2069 (TTY: 1-877-206-0500)

Fax: 1-844-430-1705

Mailing: 3250 Mary Street Suite 400, Coconut Grove, FL 33133

This table shows you the timeframe of when you can expect our decision on your request for medical care and prescription drug coverage

(calendar days). 

   Medical Coverage Part D & Part B Drugs
 Standard Decision  14 Days  72 Hours
 Fast Decision (“expedited”)  72 Hours  24 Hours

 

HealthSun may only approve your request for an exception if the alternative drug is included on our Formulary. The lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

IMPORTANT: If your health requires a quick response, you should ask the plan to make a fast decision. To get a fast decision, you must ask for it and the plan will decide if your health requires a Fast Decision. To qualify, you must be asking for coverage on medical care or a drug that you have not yet received. You must also indicate that the standard timeframe could cause serious harm to your health or impair your ability to function. If your physician tells us that your health requires a Fast Decision, the plan will automatically agree to give you a Fast Decision. 

2020 Prescription Coverage Determination Request Form
2020 B vs. D Coverage Determination Request Form
CMS Model Medicare Prescription Drug Coverage Determination Request Form 

These forms are not required. 

Request a Payment

For more information, please see Chapter 9 in your plan’s Evidence of Coverage (EOC).

A reimbursement or a payment for a bill you have received from a provider for covered medical services or drugs.

You can send your request in writing to our main office. The request must be made by you or your appointed representative.

The payment request must include a bill or documentation of payment. 

Medical Coverage: 

Member Services Phone: 1-877-336-2069 (TTY: 1-877-206-0500)

Fax: 305-448-5783

Mailing: 3250 Mary Street Suite 400, Coconut Grove, FL 33133

 

Part D & Part B Drugs:

Member Services Phone: 1-877-336-2069 (TTY: 1-877-206-0500)

Fax: 1-401-652-1911

Mailing: PO Box 52077, Phoenix, AZ 85072-2077

E-mail (secure access): RxPaperClaim_AnthemMEDD@CVSHealth.com

You must submit your claim to us within 30 days of the date from when you received the service, item, or drug. It is a good idea to make a copy of your documents for your records. You can use our Reimbursement Request Form to help us process the information faster.

Reimbursement Request Form
Part D Reimbursement Request Form
The Reimbursement Forms are not required. 

Request an Appeal

For more information, please see Chapter 9 in your plan’s Evidence of Coverage (EOC).

An appeal to review and change a coverage decision we have made on your medical care or prescription drug coverage.

You can call a HealthSun Member Service Representative or you can send your appeal in writing to our main office. The appeal request must be signed by you or your appointed representative 

Member Services Phone: 1-877-336-2069 (TTY: 1-877-206-0500)

Fax: 1-877-589-3256

Mailing: 3250 Mary Street Suite 400, Coconut Grove, FL 33133

This table shows you the timeframe of when you can expect our decision on your appeal for medical care and prescription drug coverage (calendar days).    

  Medical Coverage Part D & Part B Drugs
Standard Decision 30 Days 7 Days
Fast Decision ("expedited") 72 Hours 72 Hours


Redetermination of Medicare Prescription Drug Denial Request Form

The Grievance/Appeal Form is not required

File a Complaint

For more information, please see Chapter 9 in your plan’s Evidence of Coverage (EOC).

A complaint about us or one of our network providers, including a complaint about the quality of your care.

You can call a HealthSun Member Service Representative or you can send your complaint in writing to our main office. The complaint must be filed by you or your appointed representative.

Member Services Phone: 1-877-336-2069 (TTY: 1-877-206-0500)

Fax: 786-363-8100

Mailing: 3250 Mary Street Suite 400, Coconut Grove, FL 33133

We will provide you a response within 30 calendar days from the date that we receive your complaint. In some instances it can take up to 14 more days if you ask for more time or if we need additional information that may benefit you, in which we will notify you in writing.

You can make complaints about quality of care to the Quality Improvement Organization (QIO) instead of filing your complaint with the plan or you may file your complaint to the QIO and to our plan. If you file a complaint with the QIO we will work together with them to resolve your complaint. To obtain information to the QIO contact our Member Services Department at 1-877-336-2069.

Should you need to file a complaint with Medicare you can call 1-800-Medicare or click here to submit your complaint using the Medicare Complaint Form

Grievance/Appeal Form

This form is not required