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Making an Appeal
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. When we have completed the review, we give you our decision. If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our Plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal.
To file an appeal, please contact the Plan by calling Member Services at 1-866-245-5360. You can also send your request to our Appeals Department by mail or fax at:
Tampa, FL 33684 Fax: 1-813-506-6235
- To request a Pharmacy Exception, please contact Member Services at 1-888-407-9977.
- To make a oral request for determination (exceptions)/re-determinations (expedited appeals), call 1-888-407-9977.
For detailed instructions on the appeals process, please see "What to do if you have a problem or complaint (coverage decisions, appeals, complaints)" Section of your Evidence of Coverage. The Evidence of Coverage (EOC) is a comprehensive resource guide to your health care coverage and is considered a legal document. Just click on your plan’s name and number below to view a copy.
|Plan Name||Complete EOC||Coverage Determination||Plan Name||Complete EOC||C overage Dete rmination|
|Optimum Gold Rewards Plan (HMO-POS)||001||001||Optimum Platinum Plus (HMO-POS)||023||023|
|Optimum Platinum Plan (HMO)||002||002||Optimum Gold Rewards Plan (HMO-POS)||026||026|
|Optimum Platinum Plan (HMO-POS)||006||006||Optimum Platinum Plan (HMO-POS)||027||027|
|Optimum Emerald Partial (HMO SNP)||016||016||Optimum Diamond Rewards (HMO POS SNP)||028||028|
|Optimum Emerald Full (HMO SNP)||017||017||Optimum Diamond Rewards COPD (HMO-POS SNP)||029||029|
|Optimum Gold Rewards Plan (HMO-POS)||018||018||Optimum Diamond Rewards (HMO-POS SNP)||030||030|
|Optimum Platinum Plus (HMO-POS)||019||019||Optimum Diamond Rewards COPD (HMO POS SNP)||031||031|
|Optimum Gold Rewards Plan (HMO-POS)||022||022|
Appointment of a Representative
The Appointment of Representative Form (PDF, 66 KB) is located on the CMS Web site.
Beneficiaries and providers may appoint another individual, including an attorney, as their representative in dealings with Medicare, including appeals you file. Form CMS-1696, Appointment of Representative form, must be submitted with the appeal and is valid for one year from the date. The form must be signed by both you and the appointed representative. A representative may be designated at any point in the appeals process. This representative may assist you during the processing of a claim or claims and/or any subsequent appeal. Refer to the CMS Medicare Claims Processing Manual (PDF, 605 KB) (Pub. 100-04, chapter 29, section 270.1.10) for information on disclosing information to third parties.
The following types of individuals may be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:
- Congressional staff members
- Family members of a beneficiary
- Friends or neighbors of a beneficiary
- Members of beneficiary advocacy groups
- Members of provider or supplier advocacy groups
- Physicians or suppliers
The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (CMS-1696) or use a conforming written instrument. Refer to the CMS Medicare Claims Processing Manual (Pub. 100-04, chapter 29, section 270.1) for required elements of written instruments. You may appoint a representative at any time during the course of an appeal. The representative must sign the CMS-1696 or other conforming written instrument within 30 calendar days of the date the beneficiary or you sign an order for the appointment to be valid. By signing the appointment, the representative indicates his/her acceptance of being appointed as representative.
The CMS-1696 is available for the convenience of the beneficiary or you to use when appointing a representative. Instructions for completing the form:
- The name of the party making the appointment must be clearly legible. For beneficiaries, the Medicare Health Insurance Claim (HIC) number must be provided.
- Completing Section I - 'Appointment of Representative' - A specific individual must be named to act as representative in the first line of this section. A party may not appoint an organization or group to act as representative. The signature, address and phone number of the party making the appointment must be completed and the date it was signed must be entered. Only the beneficiary or the beneficiary’s legal guardian may sign when a beneficiary is making the appointment. If the party making the appointment is the provider or supplier, someone working for or acting as an agent of the provider or supplier must sign and complete this section.
- Completing Section II - 'Acceptance of Appointment' - The name of the individual appointed as representative must always be completed and his/her relationship to the party entered. The individual being appointed must then sign and complete the rest of this section.
- Completing Section III - 'Waiver of Fee for Representation' - This section must be completed when the beneficiary is appointing a provider or supplier as representative and the provider or supplier actually furnished the items or services that are the subject of the appeal
- Completing Section IV - 'Waiver of Payment for Items or Services at Issue' - This section must be completed when the beneficiary is appointing a provider or supplier who actually furnished the items or services that are the subject of the appeal and involve issues describe in section 1879(a)(2) of the Social Security Act
If any one of the elements listed above is missing from the appointment, the adjudicator shall contact the party (individual attempting to act as a beneficiary’s representative) and provide a description of the missing documentation or information. Unless the missing information is provided, the prospective appointed representative lacks the authority to act on behalf of the party and is not entitled to obtain or receive any information related to the appeal, including the appeal decision. The adjudicator will not dismiss the appeal request because the appointment of representative is not valid
Mail or fax this statement to the Plan at:
Grievance and Appeals Department
PO Box 152727
Tampa, FL 33684 Fax: 1-813-506-6235
You can also call the Member Services Department to learn more about how to name your appointed representative.
The plan requires prior authorization (approval in advance) of certain covered drugs that have been approved by the FDA for specific medical conditions. Contact Us for more information.