Grievance and appeals rights — Medicare

Coverage decisions, complaints, premium assistance & other important information

See chapter 9 of your plan’s Evidence of Coverage (EOC). For data on the number of grievances and appeals for Medicare Advantage plans from WellFirst Health — provided by SSM Health Plan — contact our Customer Care team at 1-877-301-3326 (TTYT: 711).

Coverage decisions

Coverage decisions are the first decision made by the plan on the medical care you are requesting or the drugs(s) or payment you need.

A standard coverage decision for medical care means we will give you an answer within 14 calendar days after we receive your request. A fast coverage decision means we will answer within 72 hours.

A standard coverage decision for drugs means we must give you our answer within 72 hours after we receive your request. For a fast coverage decision about the drug(s) or payment you need, we must give you our answer within 24 hours.

See the latest National Coverage Determination updates.

Requesting a coverage decision

To request a coverage decision for medical care, drugs or payment, you, your appointed representative or physician should contact us by telephone, fax or mail at these numbers or addresses:

Medical fax

1-608-252-0840

Drug fax

1-855-673-6507

Mail
Mailing address medical

WellFirst Health
Medicare Advantage
PO Box 56099
Madison, WI 53705-9399

Mailing address drug

WellFirst Health
Medicare Advantage
PO Box 1039
Appleton, WI 54912-1039

You, your prescriber or member representative may ask for a coverage decision via secure email outlined in the CMS drug coverage determination form.

Reimbursements

Requesting a Part D drug reimbursement

Mail or fax us a copy of the itemized prescription receipt along with a copy of the register receipt if available. Note: the register receipt alone is not adequate because it doesn’t have all pertinent information needed for reimbursement.

The itemized receipt should contain the following information:

  • Pharmacy name, address, phone number
  • Prescription (Rx) number
  • Date of service
  • Drug name
  • National drug code (NDC)
  • Quantity and day supply
  • Provider name
  • Member cost/responsibility

Mail to:

WellFirst Health
Medicare Advantage
PO Box 1039
Appleton, WI 54912-1039

Fax
1-608-252-0812 for Medical complaints
1-855-673-6507 for Part D Prescription complaints

Requesting a Part C medical reimbursement

If you are requesting reimbursement, complete the patient's request for medical payment form. Mail the form along with your bill and documentation of any payment you've made. It is a good idea to make a copy of the bill and receipts for your records. 

Mail to: 

Part C Medical

WellFirst Health
Medicare Advantage
PO Box 56099
Madison, WI 53705-9399

Part D Drug

WellFirst Health
Medicare Advantage
PO Box 1039
Appleton, WI 54912-1039


Grievance & appeals

An appeal means we will review an unfavorable coverage determination. 

A grievance is any complaint or dispute (dissatisfaction) other than one involving an organization determination. It is different from a coverage determination request; it usually will not involve coverage or payment for Part D drug benefits or Part C medical benefits.

  • We make grievance decisions as quickly as your case requires but no later than 30 calendar days after receiving your complaint.
  • If you request a fast grievance, and your request meets our fast grievance criteria, we'll render a decision within 24 hours.

In most cases, you only have 60 calendar days from an event to file a grievance or appeal. You may be eligible to file a grievance or appeal after 60 calendar days when you provide a good cause reason for missing the deadline. If we do not accept your good cause reason, we will notify you in writing.

Part D drug appeals

You can file an appeal if you want us to reconsider a decision we have made about your Part D prescription drug benefits or cost sharing associated with your Part D drug coverage.

  • A standard appeal decision means we have up to 7 calendar days from the time we receive your request to make a decision on a standard appeal.
  • A fast appeal decision means we have up to 72 hours from the time we receive your request to make a decision on a fast appeal. This must be for a Part D drug you have not received.

Part C medical appeals

You can file an appeal if you want us to reconsider a decision we have made about your Part C medical prior authorization or Part C medical claim or cost share associated with your Part C medical coverage.

A standard appeal decision means we have up to 30 days (pre-service) or 60 days (post service) from the time we receive your request to make a decision.

A fast appeal decision means we have up to 72 hours from the time we receive your request to make a decision.

Requesting a Part C medical or Part D drug grievance or appeal

You, your prescriber or member representative may ask for a redetermination (appeal) using the Medicare redetermination request form.

To check status or to request a standard or fast grievance or an appeal, you, your appointed representative or your prescribing physician should contact us by telephone, fax, mail or hand-deliver at these numbers or addresses:

Phone

1-877-301-3326

In-person

WellFirst Health
1277 Deming Way
Madison, WI 53717


Mail

Part D drug

WellFirst Health
Medicare Advantage
PO Box 1039
Appleton, WI 54912-1039

Part C medical

WellFirst Health
Medicare Advantage
PO Box 56099
Madison, WI 53705-9399

Fax

Part D drug

1-855-673-6507 for Part D Prescription complaints

Part C medical

1-608-252-0812 for Medical complaints


Part C Quality Improvement Organization (QIO) appeal

You may request a review by Livanta, a Quality Improvement Organization (QIO), if your complaint relates to one of the following situations:

  • You have a complaint about the quality of care you have received.
  • You think coverage for your hospital stay is ending too soon.
  • You think coverage for your home health care, skilled nursing facility care or Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.

Livanta can be reached at 1-888-524-9900 or by mail at the following address:

Livanta BFCC-QIO
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701

You must act quickly when filing with Livanta as a request must be made before you leave the hospital and no later than your planned discharge date.


Appointing a representative

You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Others may already be authorized by the court or in accordance with state law to act for you. If you want someone to act for you who is not already authorized by the court or under state law, then you and that person must sign and date a statement that gives the person legal permission to be your representative.

If you prefer that someone else acts on your behalf, fill out the CMS appointment of representative form and mail it. Or if you have questions, call our customer care team.


Medicare complaint form

If you have complaints or concerns about WellFirst Health Advantage plans and would like to contact Medicare directly, use the CMS complaint form.

You, your appointed representative or your prescribing physician can check the complaint status or submit a complaint by telephone, fax, mail or hand deliver at these numbers or addresses:

Phone

1-877-301-3326

Mail

Part C Medical
WellFirst Health
Medicare Advantage
PO Box 56099
Madison, WI 53705-9399

Part D Drug
WellFirst Health
Medicare Advantage
PO Box 1039
Appleton, WI 54912-1039

Fax

1-608-252-0812 for Medical complaints

1-855-673-6507 for Part D Prescription complaints

In person

WellFirst Health
1277 Deming Way
Madison, WI 53717


THE MEDICARE BENEFICIARY OMBUDSMAN

The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests. See the Ombudsman website.

Other resources

WellFirst Health

1-833-301-3326 (TTY:711)

Medicare Rights Center

1-888-HMO-9050
(1-888-466-9050)

Elder care locator

1-800-677-1116

CMS

1-800-Medicare
(1-800-633-4227)
Recorded and live help available 24 hours a day/seven days a week.
TTY: 1-877-486-2048

Prescription drug coverage rights and responsibilities for members

As a WellFirst Health Medicare Advantage member, you can:

  • Access prescription drugs at network pharmacies regardless of race, national origin, religion, physical handicap or source of payment.
  • Receive prescription medications at a network or out-of-network pharmacy in an emergency. If you have to go to an out-of-network pharmacy, you may be responsible for paying the difference between what the plan would pay for a prescription filled at a network pharmacy and what the out-of-network pharmacy charged for your prescription.
  • File a grievance and/or appeal for such things as exceptions and coverage determinations. Grievance and appeal procedures are in effect at all times.
  • Be treated with dignity, respect, and right to privacy.
  • Receive information about the plan.

Medicare prescription drug coverage and your rights

YOUR MEDICARE RIGHTS

You have the right to request a coverage determination from your Medicare drug plan if you disagree with information provided by the pharmacy. You also have the right to request a special type of coverage determination called an “exception” if you believe:

  • you need a drug that is not on your drug plan’s list of covered drugs—also called a formulary
  • a coverage rule (such as prior authorization or a quantity limit) should not apply to you for medical reasons; or
  • you need to take a non-preferred drug and you want the plan to cover the drug at the preferred drug price
What you need to do

You or your prescriber can contact your Medicare drug plan to ask for a coverage determination by calling the plan’s toll-free phone number on the back of your plan membership card, or by going to your plan’s website.

You or your prescriber can request an expedited (24 hour) decision if your health could be seriously harmed by waiting up to 72 hours for a decision. Be ready to tell your Medicare drug plan:

  • The name of the prescription drug that was not filled. Include the dose and strength, if known.
  • The name of the pharmacy that attempted to fill your prescription.
  • The date you attempted to fill your prescription.
  • If you ask for an exception, your prescriber will need to provide your drug plan with a statement explaining why you need the off-formulary or non-preferred drug or why a coverage rule should not apply to you.
  • Your Medicare drug plan will provide you with a written decision. If coverage is not approved, the plan’s notice will explain why coverage was denied and how to request an appeal if you disagree with the plan’s decision.

See your plan materials or call 1-800-Medicare for more information. Recorded and live help available 24 hours a day, seven days a week.

Disenrollment rights and responsibilities

Although WellFirst Health Medicare Advantage will never disenroll you or ask you to disenroll from our plan due to health-related reasons, there are certain circumstances that will result in your involuntary disenrollment from a WellFirst Health Medicare Advantage.

Disenrollment from WellFirst Medicare Advantage may occur if: 

  • You do not stay continuously enrolled in Medicare Part A or B (or both).
  • You move out of the service area or are away from the plan’s service area for more than six months. (Note: If you plan to move or take a long trip, we encourage you to call Member Services and ask if the place you are moving or traveling to is in the WellFirst Health service area.
  • You knowingly falsify or withhold information about other parties that provide reimbursement for your prescription drug coverage.
  • You continuously behave in a way that is disruptive and makes it difficult for us to provide care for you and other members of our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
  • You do not pay your plan’s monthly premiums; you may be notified in writing that you have a grace period during which you can pay the plan premiums before your membership ends.
  • Medicare terminates its contract with WellFirst Health, WellFirst Health Plan terminates its contract with Medicare.
  • You are determined to be unlawfully present in the United States.

If you are involuntarily disenrolled from your WellFirst Health plan, you have the right to ask us to reconsider this decision by filing a Grievance with us. If you have any questions about disenrolling from our plan, call our Customer Care Center toll-free at 1-877-301-3326 (TTY: 711).

Potential for contract termination

Availability of coverage or service areas beyond the end of the current contract year is not guaranteed. Termination or non-renewal of the contract by Centers for Medicare & Medicaid Services (CMS) or WellFirst Health as authorized by law may end your enrollment in the plan. If this occurs, you will be able to choose another plan without incurring a late enrollment penalty, as long as you do it within the time period required.