Grievances, Coverage Determinations & Appeals

As a Mercy Care Advantage member you have rights if you have a problem or complaint about the medical care you have received. Follow the menu links below to learn more about these processes.

Medicare Complaint Form

You can submit feedback about your Medicare plan directly to CMS.  To file a complaint online, visit the Medicare website.

For more information about the coverage decisions, appeals, and grievances refer to Chapter 9 of the 2018 Evidence of Coverage.

If you need help with a coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.” This may be someone who is already legally authorized to act as your representative under State law. If you want a friend, relative, or other person to be your representative you must provide a completed Appointment of Representative (AOR) form. A copy of the AOR form is available below for printing or you can contact Member Services and ask for the Appointment of Representative (AOR) form to be mailed to you.

The form must be completed and signed by you and by the person who you would like to act on your behalf. The completed and signed form is valid for one (1) year.  You are not required to use the AOR, you can also provide a written notice that contains the information below:

  1. Enrollee’s name, address, and telephone number;
  2. Enrollee’s Medicare Identifier Number
  3. The name, address, and telephone number of the individual being appointed;
  4. A statement that authorizes the representative to act on your behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to your representative;
  5. Must be signed and dated by the enrollee making the appointment; and
  6. Must be signed and dated by the individual being appointed as your representative, and is accompanied by a statement that the individual accepts the appointment.

For medical care, your doctor can request a coverage decision or a Level 1 appeal on your behalf. If your appeal is denied at Level 1, it will automatically be forwarded to Level 2.  To request any appeal after Level 2, your doctor must be appointed as your representative.

For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or Level 1 or Level 2 appeal on your behalf. To request an appeal after Level 2, your doctor or other prescriber must be appointed as your representative.

Appointment of Representative Form (English | Español)

Filing a grievance You have the right to file a complaint if you have a problem or concern. A grievance is a complaint about the care or services you have you’ve received. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times and the customer service you receive. If you have any of the complaints or problems below, you can file a complaint. Here are some examples:

 

  • You believe your plan’s customer service hours of operation should be different.
  • You believe there aren’t enough specialists in the plan to meet your needs.
  • The plan is sending you materials that you didn’t ask to get and aren’t related to your plan.
  • The plan didn’t make a decision about a reconsideration within the required timeframe.
  • The plan didn’t provide the required notices.
  • The plan’s notices don’t follow Medicare rules.

Step-by-Step: Making a Complaint

Step 1: Contact us promptly – either by phone or in writing

  • Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. You can contact Member Services at 602-263-3000 or 800-624-3879, 8:00 a.m. - 8:00 p.m., 7 days a week. TTY users should call 711.
  • If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here's how it works:
  • If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond to you in writing.
  • If we cannot resolve your complaint over the phone, we will respond to your complaint within 30 calendar days.
  • Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 days after you had the problem you want to complain about.
  • If you have asked our plan to give you a "fast response" for a coverage decision or appeal, and we have said we will not, you can make a complaint. We also must review a fast complaint if we extend a review timeframe for a determination of appeal. If you have a "fast" complaint, it means we will give you an answer within 24 hours.

Step 2: We look into your complaint and give you our answer

You can also make complaints about quality of care to the Quality Improvement Organization
You can make your complaint about the quality of care you received to our plan by using the step-by-step process outlined above.

When your complaint is about quality of care, you also have two extra options:

  • You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our plan). If you make a complaint to this organization, we will work together with them to resolve your complaint.
  • You can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization.

Livanta is Arizona's Quality Improvement Organization. You may contact Livanta at
1-877-588-1123 or by writing:

Livanta
BFCC-QIO Program
9090 Junction Drive, Suite 10 Annapolis Junction, MD 20701
1-877-588-1123
TTY: 1-855-887-6668
Fax:
Appeals: 1-855-694-2929
All other reviews:
1-844-420-6672

See chapter 9 for information about complaints and grievances in the 2018 MCA Evidence of Coverage

If you would like to learn how many appeals, grievances and exceptions Mercy Care Advantage has processed, please contact our representatives at 602-263-3000 or 1-800-624-3879, TTY users should call 711, 8:00 a.m. - 8:00 p.m., 7 days a week.

Service determinations
When you, your doctor or your representative request an authorization for a service or benefit, MCA will notify you of our determination by mail not later than 14 calendar days after we receive your request. If you or your doctor requests a fast (expedited) review, and we agree that waiting for the standard timeframe of 14 days will seriously affect your life, health or ability to regain maximum function, we will notify you by telephone of our determination not later than 72 hours after we receive your request. If we do not agree a fast review is required, we will notify you and automatically move your request to the standard review process. If our determination is unfavorable to you, you or your representative may file an appeal of our decision.

Payment determinations
When you receive health care from providers, they must submit a claim for those services. Claims are paid based on the information the provider supplies and your benefits under Mercy Care Advantage. If payment for a claim is denied, and we believe you may be responsible for the payment, we will send you a letter that explains why we did not pay for the services. You or your representative has the right to appeal the determination.

You may request coverage for a medical service or item you feel should be covered by Mercy Care Advantage by contacting Member Services at:  

Mercy Care Advantage Members:
602-263-3000 in the Phoenix Metro area
1-800-624-3879 (calls to this number are free)
TTY users: 711
Hours of operation: 8:00 a.m. - 8:00 p.m., 7 days a week

Fax number: 602-351-2313

To contact us by mail:
Mercy Care Advantage
Attn: Grievance Department
4350 E. Cotton Center Blvd., Bldg. D
Phoenix, AZ 85040

 

Appointment of representative

If you need help with a coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.” If you want a friend, relative, or other person to be your representative, call Member Services and ask for the Appointment of Representative form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You can also print a copy of the Appointment of Representative form (English | Español). The completed and signed form is valid for one (1) year.

Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision a Level 1 or Level 2 Appeal on your behalf. To request any appeal after Level 2, your doctor or other provider must be appointed as your representative. If your representative holds durable power of attorney or guardianship papers, an Appointment of Representative form is not required.

 

Appeals
As a Mercy Care Advantage member, you have the right to file an appeal (called a “reconsideration”) with us if you receive notice of any of the following:

  • Mercy Care Advantage denied payment for renal dialysis services you received while temporarily outside of the Mercy Care Advantage service area
  • Mercy Care Advantage denied payment for emergency services, post-stabilization care or urgently needed services you received while temporarily outside of the Mercy Care Advantage service area
  • Mercy Care Advantage denied payment for any other health services furnished by a provider that you believe should be covered
  • Mercy Care Advantage refused to authorize, provide or reimburse you for services, in whole or in part, that you believe should be covered
  • Mercy Care Advantage failed to approve, furnish, arrange for, or provide payment for health care services in a timely manner

Once you receive a written notification, you may file an appeal within 60 days from the date of the notification letter. You can call or write a letter to Mercy Care Advantage to file an appeal. A special team will review your appeal to determine if we made the right decision. For authorization decisions, we will notify you in writing of the results of our reconsideration not later than 30 calendar days from the date your appeal was received. For payment decisions, we will notify you in writing not later than 60 calendar days.

Oral appeal requests can be made by calling 1-800-624-3879 or 602-453-6098. TTY/TDD users should call 711.

Mail your appeal to:

Mercy Care Advantage
Appeals Department
4350 E. Cotton Center Blvd., Bldg. D
Phoenix, AZ 85040

You can also fax your appeal to: 602-351-2300

If more time is needed to gather medical records from your physicians, we may file a 14-day extension. You may also request an extension if you need more time to present evidence to support your appeal. We will notify you in writing if an extension is required.

The expedited appeals (redetermination) process
You may file a request for an expedited appeal if you believe that applying for the standard appeals process could jeopardize your health. If Mercy Care Advantage decides that the timeframe for the standard process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited.

1. You, your appointed representative or your doctor can request an expedited appeal. An expedited request can be submitted orally or in writing to Mercy Care Advantage, and your doctor may need to provide oral or written support for your request for an expedited appeal.

2. Mercy Care Advantage must provide an expedited appeal if it determines that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.

3. A request made or supported by your doctor will be expedited if he/she tells us that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.

There are five levels to the Medicare Advantage appeals process for denied services and payment:

Appeal level

1. Reconsideration by Mercy Care Advantage

2. Reconsideration by the Independent Review Entity (IRE)

3. Administrative Law Judge (ALJ)

4. Medicare Appeals Council (MAC)

5. Federal District Judge

Standard review

Upon receipt of your appeal, Mercy Care Advantage will send you a letter to confirm the basis of the appeal. The reconsideration will be evaluated by an Appeals specialist, with a clinical expert when necessary. Mercy Care Advantage will notify you in less than 30 calendar days for service requests (plus 14 days if an extension is filed) or in less than 60 calendar days for payment reconsiderations.

If Mercy Care Advantage agrees with the original denial, in whole or in part, the file is automatically forwarded for reconsideration to the IRE. The IRE will review the appeal and notify of their decision within 30 days for service requests and 60 days for payment requests from the day it is received by the IRE.

If the IRE decision is unfavorable and the amount in dispute meets the appropriate threshold, you may request a hearing with the ALJ. You must follow the instructions on the notice from the IRE.

If the ALJ decision is unfavorable, you may appeal to the MAC, which is within the Department of Health and Human Services, which reviews ALJ's decisions.

If you do not want to accept the decision, you might be able to continue to the next level of the review process. It depends on your situation. Whenever the reviewer says no to your appeal, the notice you get will tell you whether the rules allow you to go on to another level of appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal.

Expedited (fast) review

Only available for reconsiderations for services not yet received. Subject to expedited review criteria. Mercy Care Advantage will notify you if the appeal does not meet expedited review criteria. Mercy Care Advantage will notify you of the reconsideration decision as fast as your condition requires, but not later than 72 hours after receiving your appeal.

If Mercy Care Advantage agrees with the original denial, in whole or in part, your file is automatically forwarded to the IRE for reconsideration within 24 hours. The IRE will review your appeal and notify you of their decision within 72 hours of receipt of the appeal file from Mercy Care Advantage.

Same as standard appeal.

Same as standard appeal.

Same as standard appeal.

Appointment of representative

If you need help with a coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.” If you want a friend, relative, or other person to be your representative, call Member Services and ask for the Appointment of Representative form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You can also print a copy of the Appointment of Representative form (English | Español). The completed and signed form is valid for one (1) year.

Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision a Level 1 or Level 2 Appeal on your behalf. To request any appeal after Level 2, your doctor or other provider must be appointed as your representative. If your representative holds durable power of attorney or guardianship papers, an Appointment of Representative form is not required.

 

See chapter 9 for information about Coverage Determinations and Appeals in the 2018 Evidence of Coverage.

 

Mercy Care Advantage
Appeals Department
4350 E. Cotton Center Blvd. Bldg. D
Phoenix, AZ 85040
Phone: 602-453-6098 or 1-800-624-3879
Fax: 602-351-2300

If you would like to learn how many appeals, grievances and exceptions MCA has processed, please contact our representatives at 602-263-3000 or 1-800-624-3879, TTY users should call 711, 8:00 a.m. - 8:00 p.m., 7 days a week.

How to file a grievance

You have the right to file a complaint (also called a “grievance”) if you have a problem or concern. A grievance is any complaint or dispute, other than one that involves a coverage determination or an LIS (Low-Income Subsidy) or LEP (Late Enrollment Penalty) determination, expressing dissatisfaction with any aspect of the operations, activities or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times and the customer service you receive.

You may file a grievance if you have a problem with Mercy Care Advantage or one of our network providers or pharmacies. Some examples of why you might file a complaint/grievance include:

    • You believe your plan’s customer service hours of operation should be different.
    • You have to wait too long for your prescription.
    • The plan is sending you materials that you didn’t ask to get and aren’t related to the drug plan.
    • The plan didn’t make a timely decision about a coverage determination in level 1 and didn’t send your case to the IRE.
    • You disagree with the plan’s decision not to grant your request for an expedited (fast) coverage determination or first-level appeal (called a “redetermination”).
    • The plan didn’t provide the required notices.
    • The plan’s notices don’t follow Medicare rules.

We may use your complaint type to track trends and identify service issues. Please see Chapter 9 of the 2018 Evidence of Coverage for detailed information and timelines for filing a grievance.

If you want to file a grievance, contact us promptly – either by phone or in writing. Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. You can reach Member Services at 602-263-3000 or 1-800-624-3879, TTY users should call 711, 8:00 a.m. - 8:00 p.m., 7 days a week.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here’s how it works:

  • If you ask for a written response, file a written grievance or your complaint is related to quality of care, we will respond to you in writing.
  • If we cannot resolve your complaint over the phone, we will respond to your complaint within 30 calendar days.

Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 days after you had the problem you want to complain about. If you need an interpreter, one can be provided at no cost to you. Please submit written complaints to the address below, or by faxing them to 602-351-2313.

Mercy Care Advantage
Attn: Member Services
4350 E. Cotton Center Blvd., Bldg. D
Phoenix, AZ 85040

You may file a request for a "fast complaint" (expedited grievance) if you disagree with our decision not to process your request for a "fast response" to a coverage decision or appeal. If you request a fast complaint, we must give you an answer within 24 hours.

If you have a complaint about your quality of care, you may file a grievance with the plan by calling Member Services and filing the complaint over the phone. The plan Quality Team will research the complaint and send a response to you. You may also file a grievance with Arizona's Quality Improvement Organization, Livanta at 1-877-588-1123.

Livanta
BFCC-QIO Program
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701
1-877-588-1123 TTY: 1-855-887-6668
Appeals: 1-855-694-2929
All other reviews: 1-844-420-6672

If you would like to learn how many appeals, grievances and exceptions Mercy Care Advantage has processed, please contact our representatives at 602-263-3000 or 1-800-624-3879, TTY users should call 711, 8:00 a.m. - 8:00 p.m., 7 days a week.

As a member of the Mercy Care Advantage (MCA) health plan, you, your authorized representative or your doctor have the right to request a coverage determination or exception for a drug that you feel should be covered for you or to pay for a prescription drug you already bought. If your pharmacist tells you that your prescription drug claim was rejected, you will be given a written notice that explains how you can request a coverage determination or exception. This information is also explained in chapter 9 of the Mercy Care Advantage Evidence of Coverage.

Mercy Care Advantage has a list of covered Part D prescription drugs called a “formulary.” Your network doctor will refer to the formulary and typically prescribe a drug from the formulary that will meet your medical needs. Not all prescription drugs are included on the Mercy Care Advantage formulary, and some drugs covered under our formulary may require prior authorization, step therapy or have quantity limits that apply. Click to view the Mercy Care Advantage Formulary Updated 11/2018.

A coverage determination is any determination (i.e., an approval or denial) made by Mercy Care Advantage for the following reasons:

1. A decision about whether to provide or pay for a Part D drug (including a decision not to pay) because:

  • the drug is not on the plan’s formulary
  • because the drug is determined not to be medically necessary
  • because the drug is furnished by an out-of-network pharmacy
  • because Mercy Care Advantage determines that the drug is otherwise excluded under section 1862(a) of the Act (if applied to Medicare Part D) that the enrollee believes may be covered by the plan

2. Failure to provide a coverage determination in a timely manner, when a delay would adversely affect the health of the enrollee; 

3. A decision concerning a tiering exceptions request;

4. A decision concerning a formulary exceptions request;

5. A decision on the amount of cost sharing for a drug; or

6. A decision whether an enrollee has, or has not, satisfied a prior authorization or other utilization management requirement.

There may be times that you, your authorized representative, or your doctor will want to ask for a coverage determination or exception. Mercy Care Advantage must review and process the request within the expedited or standard timeframes required by Medicare. If we approve the request, you will be notified and the drug or payment will be provided. If we deny the request, you will be notified and receive a written notice explaining why it was denied and how you can appeal this decision. An unfavorable decision could be because the drug is not on the formulary, excluded from Part D coverage, determined not to be medically necessary, or you have not tried a similar drug listed on the formulary.

Coverage determination requests can be made in writing, by phone or by fax. Members can call Mercy Care Advantage Member Services at the numbers provided below to request a coverage determination or exception. You may also use the Request for Coverage Determination Form to submit your request.

Coverage Determination Form:

Coverage Determination Form: Submit online
Coverage Determination Form: Download and print

Providers can call or fax a coverage determination or exception request to Mercy Care Advantage at the numbers below. A request for an exception needs to include a supporting statement from your doctor to provide the medical reasons for the drug requested.

Coverage Decisions for Part D Prescription Drugs

Mercy Care Advantage Members:
602-263-3000 in the Phoenix Metro Area
1-800-624-3879 (calls to this number are free)
TTY users: 711 
Hours of Operation: 8:00 a.m. - 8:00 p.m., 7 days a week

Fax Number:
Mercy Care Advantage
Part D Coverage Determination
Fax: 1-855-230-5544

Write:
Mercy Care Advantage
Part D Coverage Determination Pharmacy Department
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040

Description

Request to Satisfy a Prior Authorization (PA) or other utilization management (UM) requirement

Request to Waive a Prior Authorization (PA) or other utilization management (UM) requirement – Formulary Exception Request

Request for Reimbursement for drug already received that involves waiving a Prior Authorization (PA) or other utilization management (UM) requirement – Exception Request

Request for Tiering Exception - drug not yet received

Request for Tiering Exception Reimbursement

Standard coverage determination timeframe

MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but not later than 72 hours from the receipt of the request.

If an enrollee or an enrollee's prescribing physician or other prescriber is asking MCA to waive a PA or other UM requirement because the physician or other prescriber feel that the enrollee would suffer adverse effects if he or she were required to satisfy the PA requirement, this is considered an exception request. The prescribing physician or other prescriber must submit a statement to support this type of request.

 

MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 72 hours after receiving the physician’s or other prescriber's supporting statement for standard cases.

If an enrollee is asking to be reimbursed for a drug purchased that requires MCA to waive a PA or other UM requirement because the physician or other prescriber feel that the enrollee would suffer adverse effects if he or she were required to satisfy the PA requirement, this is considered an exception request. The prescribing physician or other prescriber must submit a statement to support the request.

 

MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision (and make payment when appropriate) no later than 14 calendar days after receiving the request.

If an enrollee wishes to obtain a tiering exception for a drug not yet received, his or her prescribing physician or other prescriber must provide the plan sponsor with a statement to support the request.

 

MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 72 hours after receiving the physician’s or other prescriber's supporting statement.

If an enrollee is asking for a reimbursement related to a tiering exception. The prescribing physician or other prescriber must submit a statement to support the request.

 

MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision (and make payment when appropriate) no later than 14 calendar days after receiving the request.

Expedited coverage determination timeframe

MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 24 hours after receiving the request.

If an enrollee or an enrollee's prescribing physician or other prescriber is asking MCA to waive a PA or other UM requirement because the physician or other prescriber feel that the enrollee would suffer adverse effects if he or she were required to satisfy the PA requirement, this is considered an exception request. The prescribing physician or other prescriber must submit a statement to support the request.

 

MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 24 hours after receiving the physician’s or other prescriber's supporting statement for expedited cases.

Reimbursement requests do not qualify for expedited processing.

If an enrollee wishes to obtain a tiering exception for a drug not yet received, his or her prescribing physician or other prescriber must provide the plan sponsor with a statement to support the request.

 

MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 24 hours after receiving the physician’s or other prescriber's supporting statement.

Reimbursement requests do not qualify for expedited processing.

Appointment of representative If you need help with a coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.” If you want a friend, relative, or other person to be your representative, call Member Services and ask for the Appointment of Representative form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You can also click here to print a copy of the Appointment of Representative form (English | Español). The completed and signed form is valid for one (1) year.

Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision a Level 1 or Level 2 Appeal on your behalf. To request any appeal after Level 2, your doctor or other provider must be appointed as your representative. If your representative holds durable power of attorney or guardianship papers, an Appointment of Representative form is not required.

Appeals
If you are notified of a coverage determination denial by Mercy Care Advantage, you or your appointed representative may submit a redetermination request (1st level of appeal) within 60 calendar days from the date of the written notice. You may submit an appeal after this timeframe if you have good cause.

You may submit a redetermination request by calling Mercy Care Advantage or sending a request in writing. You or your physician may request a fast (expedited) appeal if it is believed that applying the standard timeframe could seriously affect your health. If Mercy Care Advantage does not agree, you will be notified and your redetermination will be automatically moved to the standard process.

Redetermination Request Form:

To submit a redetermination request call 602-453-6098 or 1-800-624-3879. TTY/TDD users should call 711.

Mail your redetermination request to:

Mercy Care Advantage
Appeals Department
4350 E. Cotton Center Blvd., Bldg. D
Phoenix, AZ 85040

You can also fax your redetermination request to: 602-351-2300

When you or your representative requests a redetermination, a special team will review your request, collect evidence and findings that the denial was based on and any additional evidence from you or your doctors. The case will then be reviewed by a different physician than the one who made the original determination. Mercy Care Advantage will notify you and your doctor of the redetermination decision, following the timeframes below.

If Mercy Care Advantage fails to make a redetermination decision and notify you within the timeframe, Mercy Care Advantage must submit your redetermination case file to IRE for review. Mercy Care Advantage will notify you if this action should occur. You have the right to a timely redetermination (see table below) and may file an expedited grievance if we do not notify you of our decision within this timeframe (see Grievances).

If Mercy Care Advantage notifies you of an unfavorable decision, and you disagree, you may submit a reconsideration request (second-level appeal) to the Independent Review Entity. Additional instructions will be included in the written notice.

Description

1. Redetermination by Mercy Care Advantage

2. Reconsideration by Independent Review Entity (IRE)

3. Hearing with Administrative Law Judge (ALJ)

4. Review by Medicare Appeals Council (MAC)

5. Federal District Judge

Standard appeal

Upon receipt of your appeal (redetermination), the Appeals Unit Coordinator will gather evidence on the basis of the denial of the Part D prescription drug, and additional evidence from you or your representative and prescribing doctor.

Your appeal will be evaluated by a clinical expert.

Mercy Care Advantage will notify you by telephone as fast as your health condition requires but not later than 7 calendar days from the receipt of the appeal.

If Mercy Care Advantage upholds the original denial for your prescription drug, you may send your appeal to the CMS-contracted IRE within 60 calendar days of the Mercy Care Advantage notice. The IRE will review your appeal and make a decision within 7 calendar days.

If the IRE decision is unfavorable and the amount in dispute meets the requirements, you may request a hearing with the ALJ. You must follow the instructions on the notice from the IRE.

If the ALJ decision is unfavorable, you may appeal to the MAC, which is within the Department of Health and Human Services. The MAC oversees the ALJ decisions.

If you do not want to accept the decision, you might be able to continue to the next level of the review process. It depends on your situation. Whenever the reviewer says no to your appeal, the notice you get will tell you whether the rules allow you to go on to another level of appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal.

Expedited appeal

You or your doctor may request Mercy Care Advantage to expedite your appeal if it believes that waiting for the standard timeframe will cause you serious harm.

Mercy Care Advantage will notify you of the decision by telephone as fast as your health condition requires but not later than 72 hours after receipt of your appeal.

If Mercy Care Advantage does not agree that your appeal requires a fast review, you will be notified that the standard timeframe will be applied.

You may file a fast appeal with the IRE if you or your doctor believes that waiting for the standard timeframe will cause you serious harm. The IRE will review your appeal and notify you if they do not agree that your appeal requires a fast review, and will apply the standard timeframe. If the IRE agrees, they will notify you of their decision within 72 hours from the time your appeal was received.

Same as standard appeal.

Same as standard appeal.

Same as standard appeal.

More information on appeals.

The prescription drug coverage expedited appeals (redetermination) process
You may file a request for an expedited appeal for drug coverage if you believe that applying the standard appeals process could jeopardize your health. If Mercy Care Advantage decides that the timeframe for the standard process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited.

  1. You, your appointed representative or your doctor or other prescriber can request an expedited appeal. An expedited request can be submitted orally or in writing to Mercy Care Advantage and your doctor or other prescriber may provide oral or written support for your request for an expedited appeal.
  2. Mercy Care Advantage must provide an expedited appeal if it determines that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.
  3. A request made or supported by your doctor or other prescriber will be expedited if he/she tells us that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.

Appointment of representative

If you need help with a coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.” If you want a friend, relative, or other person to be your representative, call Member Services and ask for the Appointment of Representative form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You can print a copy of the Appointment of Representative form (English | Español). The completed and signed form is valid for one (1) year.

Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision a Level 1 or Level 2 Appeal on your behalf. To request any appeal after Level 2, your doctor or other provider must be appointed as your representative. If your representative holds durable power of attorney or guardianship papers, an Appointment of Representative form is not required.

Coverage Determination Form:

Please see chapter 9, section 7 for more information about Part D prescription drug coverage determinations and appeals in the 2018 Evidence of Coverage.

If you would like to learn how many appeals, grievances and exceptions Mercy Care Advantage has processed, please contact our representatives at 602-263-3000 or 1-800-624-3879, TTY users should call 711, 8:00 a.m. - 8:00 p.m., 7 days a week.