CareAdvantage Cal MediConnect Plan (Medicare-Medicaid Plan)
Drug Coverage Redetermination
If you disagree with a Part D drug coverage decision that HPSM makes, you can submit an appeal. This is called a coverage redetermination or plan redetermination.
When you first submit a request for coverage redetermination, it is called a Level 1 Appeal. To begin the process, either fill out and submit the CareAdvantage CMC Determination Request form or call the CareAdvantage Unit.
There are two types of appeals:
We will give you a response within seven calendar days of receiving your appeal. If we do not give you a decision within that timeframe, we are required to send your request on to Level 2 of the appeals process (described below).
For a Fast Appeal (also known as a Expedited Appeal or Expedited Redetermination), we will give you a response within 72 hours after we receive your request. But you can only get a fast coverage decision if:
- Using the standard deadlines could cause serious harm to your health or hurt your ability to function
- You are asking us to pay you back for a drug that you already bought
- You have not received the drug your doctor prescribed
The Appeal Process
Your initial request is a Level 1 Appeal. If HPSM approves your request, then the process ends there. If we deny your request, you can appeal the decision again, as there are a total of five appeal levels.
Level 1 Appeal
You must make your appeal request within 60 calendar days from the date on the written coverage decision HPSM sent you. You have the right to ask HPSM for a copy of the information regarding your appeal. You and your doctor or other prescriber may give us additional information to support your appeal.
If we agree to part or all of your Level 1 Appeal, we must provide the coverage we have agreed to as quickly as your health requires, but no later than seven calendar days after we receive your appeal. If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.
If we deny part or all of your Level 1 Appeal, we will provide you with a written explanation of our decision. If you disagree with our decision, you can initiate a Level 2 Appeal. Our response to your Level 1 Appeal will include instructions on how to make a Level 2 Appeal.
Level 2 Appeal
A Level 2 Appeal is a review by an Independent Review Organization (IRO) that is not connected to HPSM or CareAdvantage CMC. You (or your representative, doctor or other prescriber) must ask the IRO to review your case. Contact information for the IRO will be included in our response to your Level 1 Appeal.
When you make an appeal to the IRO, we will send the information we have about your appeal to this organization. This information is called your "case file." You have the right to ask us for a copy of your case file. You also have the right to give the IRO additional information to support your appeal.
Just like a Level 1 Appeal, you can request a Standard or Fast Level 2 Appeal, and the same criteria apply at both levels. Whichever type you request, the IRO will review your appeal and decide whether it should be reconsidered. If they agree that it should, and it is a Standard Appeal, they will inform you in writing of their decision within seven calendar days of receiving your appeal. If it is a Fast Appeal, they will respond within 72 hours of receipt.
If the IRO overturns HPSM's decision, we are legally required to comply. We must provide the drug coverage that was approved by the IRO within 72 hours of receiving the review organization's decision. If the IRO approves a request for us to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days of receiving their decision.
If the IRO rejects your Level 2 Appeal, it means they agree with our decision not to approve your request. This is called “upholding the decision” or “turning down the appeal.” In that case, you may be able to initiate a Level 3 Appeal.
Level 3-5 Appeals
In order to make a Level 3 Appeal, the dollar value of the drug coverage you are requesting must meet a minimum amount. The notice you get from the IRO to your Level 2 Appeal will tell you the dollar value.
If it is too low, the Level 2 Appeal decision is final and you cannot make another appeal.
If the dollar value of the coverage you are requesting meets the requirement, you may choose to make a Level 3 Appeal. The written notice from the IRO will include instructions.
Level 3 Appeals are handled by an administrative law judge, and you must appoint your doctor or other prescriber as your representative.
If your Level 3 Appeal is rejected, there are two additional appeal levels (for a total of five appeal levels).
To Request a Coverage Redetermination
Complete the CareAdvantage CMC Redetermination Request, then:
- Fax it to 650-829-2002
- Or mail it to:
Health Plan of San Mateo
c/o Pharmacy Services: Coverage Redetermination
801 Gateway Blvd., Suite 100
South San Francisco, CA 94080
CareAdvantage Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Limitations and restrictions may apply. For more information, call the CareAdvantage Unit or read the CareAdvantage Member Handbook.
Benefits and co-pays may change on January 1 of each year.
If you speak other languages other than English, language assistance services, free of charge, are available to you. Call 1-866-880-0606 (TTY: 1-800-735-2929). (Download this statement in multiple languages.)
Page updated January 01, 2019