This form is for providers to request an appeal after they receive an adverse coverage decision (PA, Claim). Supporting documentation must be uploaded; this may include, but is not limited to: medication history, diagnostic workup, lab results, chart notes, etc.
Who May Request a Level 1 Appeal
Part C - Standard Pre-Service/Expedited Pre-Service
The enrollee’s treating physician acting on behalf of the enrollee or staff of physician’s office acting on said physician’s behalf (e.g., request is on said physician’s letterhead or otherwise indicates staff is working under the direction of the provider).
Standard Payment Reconsideration
Non-contract provider (see §50.1.1 for non-contract provider payment appeals).
Part D - Standard or Expedited Redetermination
An enrollee’s prescribing physician, another prescriber acting on behalf of the enrollee, or the staff of a physician’s office acting on a physician’s behalf (e.g., request is on the office’s letterhead).
Important Note for Expedited Decisions
Medical Item/Service - If you believe that waiting 30 days for a standard decision could seriously harm your patient’s life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. You cannot request an expedited appeal if you are asking us to pay for a service/item the member has already received.
Medicare Prescription Drug - If you believe that waiting 7 days for a standard prescription drug decision could seriously harm your patient’s life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision.