Because we, Health Choice Generations HMO, denied your request for coverage of (or
payment for) a prescription drug, you have the right to ask us for a redetermination
(appeal) of our decision. You have 60 days from the date of our Notice of Denial
of Medicare Prescription Drug Coverage to ask us for a redetermination.
Expedited appeal requests can be made by phone at 1-800-656-8991.
Who May Make a Request: Your 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. Contact
us to learn how to name a representative.
Representation documentation for appeal requests made by someone other than
enrollee or the enrollee's prescriber:
Attach documentation showing the authority to represent the enrollee (a completed
Authorization 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.
Important Note: Expedited Decisions
If you or your prescriber believe that waiting 7 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. If your prescriber indicates that waiting
7 days could seriously harm your health, we will automatically give you a decision
within 72 hours. If you do not obtain your prescriber's support for an expedited
appeal, we will decide if your case requires a fast decision. You cannot request
an expedited appeal if you are asking us to pay you back for a drug you already
CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS
Please explain your reasons for appealing. Attach additional pages,
if necessary. Attach any additional information you believe may help your case,
such as a statement from your prescriber and relevant medical records. You may
want to refer to the explanation we provided in the Notice of Denial of Medicare
Prescription Drug Coverage.
Signature of person requesting the appeal (the enrollee, or the enrollee's prescriber