What is a Redetermination?
If we make a coverage determination and you are not satisfied with our decision you can “appeal” the decision. Requesting an appeal means asking us to reconsider – and possibly change – our decision. An appeal is also known as a plan “redetermination”. If we deny coverage or payment for an item or prescription that you think we should cover or pay for, you may request an appeal.
How do I request an appeal?
You, your doctor or prescriber, or appointed representative may request an appeal by phone, mail or fax. Your redetermination can be requested 24 hours a day, 7 days a week. You can also submit your redetermination request online. You have 60 days from the date of denial of your coverage determination to ask us for a redetermination.
Call Us: 855-586-2573 (TTY: 711)
When you mail or fax your request, we recommend filling out then printing our Redetermination Request Form to ensure you are providing all the information needed for us to process your request. The denial notice you received from our coverage determination will also include a pre-printed copy of the Redetermination Request Form.
Mail the Request: Granite Alliance P.O. Box 1382 Maryland Heights, MO 63043
Fax Us: 1-888-656-8099
What happens when I request an appeal?
Once Granite Alliance receives a redetermination request, we review the original coverage determination we made to check to see that we were following all the rules properly. We may reach out to your doctor or prescriber to get additional information. Your appeal will be handled by a different reviewer than the person who made the original decision. This process ensures that we give your request a thorough review, independent of the original review.
If your request is a standard appeal, once we receive your request, we must give you our answer within seven (7) calendar days. We will give you our decision sooner if you have not yet received the drug and your health condition requires us to do so.
If you are appealing a decision, we made about a drug you have not yet received and you and your doctor or prescriber believe that your health requires it, you should ask for a “fast” appeal. A “fast” appeal is also called an “expedited redetermination”. For a “fast” appeal, we must give you our answer within 72 hours after we receive your request.
If we are unable to make the timeframes indicated above, we will automatically forward your request to an Independent Review Organization (IRE) to decide on our behalf.
What if I still do not agree with the decision of my appeal?
When you submit a request for an appeal that is considered a “Level 1” appeal. If we say no to your appeal, you can choose whether to accept our decision or continue by making another appeal. This second appeal is called a “Level 2” appeal. Level 2 appeals are reviewed by an independent review entity (IRE) which has a contract with the Centers for Medicare & Medicaid Services (CMS). To submit a Level 2 appeal, you, your representative, your doctor, or prescriber must contact the IRE and ask for a review of your case. If we deny your Level 1 appeal, the written notice we send you will include the IRE information along with a reconsideration request form. You must send your written request to the IRE within 60 calendar days of the date we notified you of our decision. After it receives your appeal the IRE will respond to your request within seven (7) calendar days (for standard requests) or 72 hours (for expedited requests).
Are there additional levels of appeal?
If the IRE says no to your Level 2 appeal (called upholding the decision), you can continue to request reviews at additional levels of appeal:
- Appeal Level 3: You may ask for a review by an Administrative Law Judge (ALJ) if the value of the drug you have appealed meets a certain dollar amount. The ALJ works for the federal government. This request must be made in writing within 60 calendar days from the date you received notification of the IRE decision. The decision you receive from the IRE will tell you if you meet the requirement, how to file this appeal and explain who may file it. If the drug’s dollar amount is less than the required amount, you cannot appeal any further. Appeal Level 4: If the ALJ says no to your Level 3 appeal, you may ask for a review by the Medicare Appeals Council (MAC). The MAC works for the federal government. You must make the request in writing within 60 calendar days of the date you were notified of the decision made by the ALJ. The decision you receive from the ALJ will tell you how to file this appeal, including who may file it.
- Appeal Level 5: If the MAC says no to your Level 4 appeal or decided not to review your appeal, you may be allowed to continue your appeal by asking a Federal Court Judge to review your case. The MAC’s Level 4 appeal notice will tell you whether the rules allow you to go on to a Level 5 appeal. To receive a review by a Federal Court Judge, the amount involved must meet the minimum requirement specified in the MAC's decision. You must make the request in writing within sixty (60) calendar days from the date of the notice of the MAC's decision. The Level 5 appeal is the last step of the appeals process.
If my appeal is approved, what happens?
If during any level of appeal your request is approved, we must provide the coverage you have requested as quickly as your health requires. The timeframe for our response depends on the level of appeal for your request.
- Level 1 Appeal: For “fast” appeals we will provide coverage within 72 hours. For “standard” appeals we will provide coverage within 7 calendar days.
- Level 2, Level 3, Level 4 and Level 5 Appeals: If the reviewing organization approves a “fast” appeal we will provide coverage within 24 hours of receiving the decision. For a “standard” appeal we will provide coverage within 72 hours.
If you have already paid for the drug, we are required to send payment to you within 30 calendar days after we received your favorable appeal decision.
For additional information on the appeals process, please review Chapter 6 of your Evidence of Coverage.