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Coverage Determination, Organization Determination, Appeal and Grievance Procedures

ApexHealth is committed to making sure you receive the care you need and the service you deserve. You have certain rights as an ApexHealth member if you experience dissatisfaction or need to receive a service, item, or drug. These rights also apply to reimbursement you’re seeking after paying for a service, item, or drug.

Part C Organization Determination
You, someone you appoint to act on your behalf, or your provider may ask us to pay for or authorize the medical care coverage you want. This is called an “organization determination”. An organization determination may be requested by:

  1. Contacting the ApexHealth Concierge Services department at (844) 279-0508 (TTY: 711). We are open 8 a.m. – 8 p.m. local time, seven days a week from October 1 to March 31, and 8 a.m. to 8 p.m. local time Monday – Friday from April 1 to September 30;
  2. Submitting your written request to:

    ApexHealth
    96 Kercheval Avenue Suite 200
    Grosse Pointe Farms, MI 48236; or
  3. Faxing your written request to: (833) 332-1877

We will decide on your request in the allowed time frame. If you are requesting us to cover a service you have not received yet, we have 14 days to decide on “standard” requests and 72 hours to decide on expedited (or “fast”) requests. If your request involves coverage for a drug covered under Medicare Part B, we will make our decision within 72 hours on “standard” requests and 24 hours on “fast” requests.

If you are requesting payment for a service you already received, we have 60 days to make a decision. You can submit a request for payment or direct reimbursement by:

  1. Completing the Direct Member Reimbursement form, attaching all supporting documentation including proof and payment and itemized bill, and mailing to:

    ApexHealth
    96 Kercheval Avenue Suite 200
    Grosse Pointe Farms, MI 48236

In limited cases, we may take up to 14 more calendar days if we find that some information that may benefit you is missing, or if you need time to get information for us to review. If you disagree with our decision to take more time to make a decision, you may file a grievance as described below in the “Grievance” section.

For ApexHealth to review an organization determination request from someone other than you, the plan must receive certain documents. These documents are described in our Appointment of Representative policy.

Part D Coverage Determination
You, someone you appoint to act on your behalf, or your provider may ask us to pay for or authorize coverage for prescription drugs you want. This is called a “coverage determination”. A coverage determination may be requested by:

  1. Contacting our Pharmacy Benefit Manager (PBM) at (800) 788-2949;
  2. Filling out the Request for Medicare Prescription Drug Coverage Determination Form on our website under “Documents and Forms” – Prescription Drug Coverage Request Form. Submit this form, along with any supporting documentation to:

    • MedImpact Healthcare Systems, Inc
      10181 Scripps Gateway Court
      San Diego, CA 92131
    • Or by faxing the form to: 858-790-7100
  3. Filing your request at https://mp.medimpact.com/partdcoveragedetermination

We will decide on your request in the allowed time frame. If you are requesting us to cover a drug you have not received yet, we have 72 hours to decide on “standard” requests and 24 hours to decide on expedited (or “fast”) requests.

If you are requesting payment for a drug you have already received, we have 14 days to make a decision. You can submit a request for payment or direct reimbursement by:

  1. Completing the Medicare Part D Prescription Drugs Claim Form, attaching all supporting documentation including receipt and prescription label, and mailing to:

    MedImpact Healthcare Systems, Inc.
    PO Box 509098
    San Diego, CA 92150-9098
  2. You may also fax the completed form and supporting documentation to: 858-549-1569 or email to claims@medimpact.com

If your request involves an “exception” we may be allowed more time to decide on your request. Exceptions may apply when the drug you are requesting is not on our formulary (list of covered drugs), or you, your appointed representative, or doctor are requesting us to waive quantity restrictions, prior authorization, or step therapy criteria. Please consult your Evidence of Coverage for further information about these restrictions.

For ApexHealth to review a coverage determination request from someone other than you, the plan must receive certain documents. These documents are described in our Appointment of Representative policy.

Grievance
A grievance is an expression of dissatisfaction with any aspect of the plan’s operations, activities, behavior, or its providers.  For example, you can file a grievance if you have concerns such as:

  • Not being able to reach the plan by telephone or having trouble receiving the information you need
  • Long wait times for doctor appointments
  • The way a provider, office staff, or pharmacy treated you
  • The quality of care you received from a provider

We will process expedited grievances within 24 hours and standard grievances within 30 days. Unless you demonstrate good cause for not filing sooner, a grievance must be filed no later than 60 calendar days after the incident that precedes the grievance.

You may also file a grievance or coverage determination request on the Medicare.gov website: www.medicare.gov/MedicareComplaintForm/home.aspx or call 1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048, 24 hours, 7 days a week.

For ApexHealth to review a grievance from someone other than you, the plan must receive certain documents. These documents are described in our Appointment of Representative policy.

Part C & D Appeals
An appeal is an action you can take if you disagree with a coverage or payment decision made by ApexHealth. For example, you can file an appeal if:

  • ApexHealth denies payment or coverage for services you think the plan should cover
  • An ApexHealth provider reduces or terminates services or benefits you have been receiving

Part C Timeframes

  • Expedited pre-service appeal: 72 hours
  • Standard pre-service appeal: 30 days (7 days for Part B Drugs)
  • Payment Appeal: 60 days

Part D Timeframes

  • Expedited pre-service appeal: 72 hours
  • Standard pre-service appeal: 7 days
  • Payment Appeal: 14 days

For ApexHealth to review an appeal request from someone other than you, the plan must receive certain documents. These documents are described in our Appointment of Representative policy.

An expedited or standard appeal may be filed by contacting:

  1. ApexHealth Concierge Services department at (844) 279-0508 (TTY: 711). We are open 8 a.m. – 8 p.m. local time, seven days a week from October 1 to March 31, and 8 a.m. to 8 p.m. local time Monday – Friday from April 1 to September 30
  2. Fax or Mail a written request for an appeal to:

    Part C Appeals
    96 Kercheval Avenue
    Suite 200
    Grosse Pointe Farms, MI 48236

    Part D Appeals
    MedImpact Healthcare Systems, Inc.
    10181 Scripps Gateway Court
    San Diego, CA 92131
    Telephone: (888) 495-3102 (TTY 711)
    Fax: (858) 790-6060

You may also submit Part D Appeals online by going to www.mp.medimpact.com/partdappeals

If you have any questions or would like more information about the coverage determination, organization determination, appeals, or grievance processes at ApexHealth, please contact Concierge Services for further assistance. You can also find information related to all these processes in your Evidence of Coverage booklet.