GRIEVANCES
It is the policy of EnvisionRx Plus to provide meaningful procedures for timely hearing and resolution of grievances. This policy enables us to use listening and problem-solving skills to resolve the issue presented. The policy also provides a protocol for escalation of grievances when warranted or requested.
What is a grievance?
A grievance is different from an appeal because usually it will not involve coverage or payment for prescription drugs included in Medicare prescription drug coverage benefits. Instead, the following types of problems might lead to you filing a grievance:
- If you feel that you are being encouraged to disenroll from EnvisionRx Plus
- Problems with the member service you receive
- Problems with how long you have to spend waiting on the phone or in the pharmacy
- Disrespectful or rude behavior by pharmacists or other staff
- Cleanliness or condition of pharmacy
- If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination
- You believe our notices and other written materials are difficult to understand
- Failure to make a decision within the required time frame
- Failure to forward your case to the independent review entity if we do not make a decision within the required time frame
How do I file a grievance?
If you would like to file a grievance, you may do so by contacting Member Services at 866-250-2005 (TTY/TTD users should call 866-763-9630), 24 hours a day, 7 days a week, or by writing to us at:
EnvisionRx Plus
P.O. Box 1298
Twinsburg OH, 44087
Fax: 1-866-250-5178
COVERAGE DETERMINATIONS
As a member of EnvisionRx Plus, you have the right to request a coverage determination concerning your rights with regard to the prescription drug coverage you are entitled to receive under your plan, including:
- Basic prescription drug coverage and supplemental benefits
- The amount including cost sharing, if any that you are required to pay for a drug
What is a coverage determination?
- A decision concerning an exception request for a plan's tiered cost sharing structure.
- A decision concerning an exception request involving a non formulary drug.
- A decision on the amount of cost sharing for a drug.
An adverse coverage determination constitutes any unfavorable decision made by or on behalf of EnvisionRx Plus regarding coverage or payment for prescription drug benefits you believe you are entitled to receive. The following actions are considered adverse coverage determinations:
- A decision not to provide or pay for a prescription drug (which includes a decision not to pay because the drug is not on the plan's formulary, determined to be not medically necessary, the drug is furnished by an out of network pharmacy or EnvisionRx Plus determines the drug is otherwise excluded under section 1862 (a) that you believe should be covered by the plan.)
- The failure to provide a coverage determination in a timely manner when a delay would adversely affect your health.
How do I request a coverage determination?
EnvisionRx Plus has both a standard and a fast (sometimes called expedited) procedure in place for making coverage determinations. When requesting a coverage determination, you should use a prior authorization form, exception request form, or coverage determination form. Links to these forms are located at the bottom of this page.
Standard Decision. A decision about whether we will cover a Medicare prescription drug (Medicare Part D) can be a "standard decision" that is made within the standard time frame (typically within 72 hours). To ask for a standard decision, you, your doctor, or your appointed representative should mail or fax your request in writing to the following:
EnvisionRx Plus
Attn: Appeals/Coverage Determinations
P.O. Box 1298
Twinsburg OH, 44087
Fax: 1-866-250-5178
Fast Decision. A decision about whether we will cover a Medicare prescription drug (Medicare Part D) can be a "fast decision" that is made more quickly (typically within 24 hours). A fast decision is sometimes called an "expedited coverage determination." You, your doctor, or your appointed representative can ask us to give a "fast" decision (rather than a "standard" decision) by calling us at 1-866-250-2005 (TTY users should call 1-866-763-9630). Or, you can deliver a written request to:
EnvisionRx Plus
Attn: Appeals/Coverage Determinations
P.O. Box 1298
Twinsburg OH, 44087
Fax: 1-866-250-5178
Be sure to ask for a "fast," "expedited," or "24-hour" review.
You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. Fast decisions apply only to requests for Medicare prescription drugs (Medicare Part D) that you have not received yet. You cannot get a fast decision if you are requesting payment for a Medicare prescription drug (Medicare Part D) that you already received.
What happens after I request a fast (expedited) decision?
If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision. If you ask for a fast initial decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast initial decision, we will send you a letter informing you that if you get a doctor’s support for a "fast" review, we will automatically give you a fast decision. You have the right to resubmit your request for an expedited coverage determination with your prescribing physician's support. The letter will also tell you how to file a "grievance" if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast initial decision, we will instead give you a standard decision (typically within 72 hours).
EnvisionRx Plus will notify you or your authorized representative, and your prescribing physician as appropriate of our decision regarding your fast request for coverage determination (and effectuate the change if favorable) as expeditiously as your health condition requires, but no later than 24 hours from the receipt of the request, or receipt of the physician's supporting statement, if provided. You will receive oral notification and your prescribing physician will receive written approval notification, if your physician provided a supporting statement.
If EnvisionRx Plus fails to make a decision regarding a fast coverage determination within the 24 hour timeframe, this constitutes an adverse coverage determination. EnvisionRx Plus, will send the request to the Independent Review Entity (IRE) designated by CMS within 24 hours of the expiration of the adjudication timeframe and the IRE will issue a determination.
APPEALS
As a member of an EnvisionRx Plus, you have the right to request an appeal to review an adverse coverage determination made by the EnvisionRx Plus on the benefits that you believe you are entitled to receive.
What is an appeal?
An "appeal" is the type of complaint you make when you want us to reconsider an adverse coverage determination we have made about what prescription drug benefits are covered for you or what we will pay for a prescription drug. This includes a delay in providing or approving drug coverage (when the delay will affect your health), or on any amounts you must pay for drug coverage. EnvisionRx Plus has both standard and fast (sometimes called expedited) appeals procedures. There are several levels of appeals that you can exercise (request for redetermination, independent review entity, ALJ hearing, and review by the Medicare Appeals Council). The first level of appeals is an appeal submitted to EnvisionRx Plus and is sometimes called a "request for redetermination." The appeal information below explains how to request a redetermination.
How do I request an appeal?
You, your appointed representative or your prescribing physician must request an appeal (request for redetermination) within 60 days of the adverse coverage determination.
Standard Appeal. You, your doctor or your appointed representative can file a standard appeal by mailing or faxing a written request to:
EnvisionRx Plus
Attn: Appeals/Coverage Determinations
P.O. Box 1298
Twinsburg OH, 44087
Fax: 1-866-250-5178
Fast Appeal. You, your doctor, or your appointed representative can file a fast (or expedited) appeal (rather than a "standard" appeal) by calling us at 1-866-250-2005 (TTY users should call 1-866-763-9630). Or, you can deliver a written request by fax or mail to:
EnvisionRx Plus
Attn: Appeals/Coverage Determinations
P.O. Box 1298
Twinsburg OH, 44087
Fax: 1-866-250-5178
Be sure to ask for a "fast," "expedited," or "72-hour" review. You may file a request for an expedited appeal for drug coverage if you believe you need and where you feel that applying the standard appeals process could jeopardize your health. Your prescribing physician may provide oral or written support for your request for a fast appeal. A request for payment of drugs that you have already received does not qualify for fast appeals processing.
What happens after I request a standard appeal?
EnvisionRx Plus will review the standard appeal (request for redetermination) and will provide you notice of our decision in writing (and effectuate the change if favorable) as expeditiously as your health condition requires but no later than 7 calendar days of receipt of the appeal request. If EnvisionRx Plus decides that the time frame for the standard appeals process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited.
What happens after I request a fast (expedited) appeal?
If EnvisionRx Plus decides that the time frame for the standard appeals process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited. A request made or supported by your prescribing physician will be expedited if the physician indicates that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function. When an appeal request meets criteria for expedited processing, EnvisionRx Plus must provide you and your prescribing physician notice of its decision (and effectuate the change if favorable) as expeditiously as your health condition requires, but no later than 72 hours after receiving the request.
If additional medical information is required to process the request, EnvisionRx Plus must request it within 24 hours of receiving the fast appeal request. Even if additional information is required, EnvisionRx Plus must still issue notice of the decision within the 72 hour timeframe.
If EnvisionRx Plus determines that your request is not time-sensitive, where your health is not seriously jeopardized, EnvisionRx Plus will notify you verbally and in writing and will automatically begin processing your request under the standard appeals process. If you disagree and believe the review should be expedited, you may file an expedited grievance with EnvisionRx Plus The written notice will include instructions on how to file an expedited grievance. You have the right to resubmit your request for an expedited appeal with your prescribing physicians support.
Failure to meet the timeframes noted constitutes an adverse determination and EnvisionRx Plus must forward your request to the Independent Review Entity (IRE) within 24 hours of the expiration of the adjudication timeframe for the IRE to issue the appeal (redetermination) decision. This applies to both standard and expedited appeal requests.
You can appoint a representative to act on your behalf by providing us with a completed Appointment of Representative Form.
Further Appeals
If you disagree with a decision EnvisionRx Plus made regarding your appeal (request for redetermination), you may file an appeal with an outside entity. For further information regarding appeals, refer to Section 5 of your Evidence of Coverage or call Member Services at 866-250-2005 (TTY users may call 1-866-763-9630). Member Services is open 24 hours a day, 7 days a week.
REQUESTS FOR INFORMATION
You may request aggregate numbers of grievances, appeals, and exceptions filed with EnvisionRx Plus, or specific information regarding grievances or appeals you have filed, by calling Member Services at 866-250-2005 (TTY users may call 1-866-763-9630). Member Services is open 24 hours a day, 7 days a week.
PRIOR AUTHORIZATION AND COVERAGE DETERMINATION FORMS
Use the following links to download forms to complete a request for prior authorization, coverage determination or exception. You should mail your completed form to EnvisionRx Plus, Appeals/Coverage Determinations, P.O. Box 1298, Twinsburg OH, 44087 or fax it to 1-866-250-5178
For more information regarding grievances, coverage determination requests, or appeals, refer to Sections 4 and 5 of your Evidence of Coverage, or call Member Services at 866-250-2005 (TTY users may call 1-866-763-9630). Member Services is open 24 hours a day, 7 days a week
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