Medical & Part D Appeal Request Form

Member

If you disagree with the decision for a request for coverage or payment for a service, you have the right to ask us for a reconsideration/redetermination (appeal) of our decision. You have 60 days from the date of our notice of denial to ask us for an appeal. For assistance with this form or questions regarding your appeal, please contact our Customer Service department at 1-877-672 8620 (TTY 711), daily from 8 a.m. to 8 p.m. PST.

Who May Make a Request: In addition to you, your physician/prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. To appoint another person to act as your representative, contact Customer Service and request an “Appointment of Representative” form.

Select Type of Appeal *

Medical Items/Service (Part C)
Medicare Prescription Drug (Part D / Part B)

Important Note: Expedited Decisions

Medical Item/Service - If you believe that waiting 30 days for a standard decision could seriously harm your 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 you back for a service/item you already received.

Important Note: Expedited Decisions

Medicare Prescription Drug - If you believe that waiting 7 days for a standard prescription drug decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision.

Are you requesting for a decision within 72 hours?

Expedited appeal requests can also be made by phone at: 1-877-672-8620 (TTY 711), daily from 8 a.m. to 5 p.m. PST.

Member Full Name *

Member ID# *

Date of Birth *

Representation documentation for appeal requests made by someone other than enrollee or the enrollee’s physician:

Attach documentation showing the authority to represent the enrollee (a completed Appointment of Representation Form CMS-1696 or a written equivalent) if it was not submitted at the coverage determination level. For more information on appointing a representative, contact your plan or 1-800 MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users can call 1-877-486-2048.

Are you submitting on behalf of someone else? *

Yes
No

Requestor's Full Name *

Relationship to member *

If representing the member, please provide your address, email and telephone number below.

Street Address *

Street Address 2

City *

Zip Code *

Email *

Telephone # *

What you are appealing *

Reference/Claim # *

Date of Service (if applicable)

Date of Decision Notice

Prescriber Name *

Office Phone *

Name of Drug

Strength/Quantity/Dose

Have you purchased the drug pending appeal? *

Yes
No

Date Purchased

Amount paid (attach a copy of receipt)

Name and telephone number of pharmacy

Please indicate the reason for the appeal and why you disagree with the original decision. Provide any additional information you think we should consider *

Please upload any supporting documentation

Medical & Part D Appeal Request Form

Member

Company

Resources

Compliance at ATRIO

Disclosures