Appeals (Parts C & D)
What is an appeal?
An appeal is a formal way of asking us to reconsider a decision that we have made about benefit coverage for you. If we make a decision that you are not satisfied with, you can ‘appeal’ it. You can appeal decisions about your medical care (reconsideration) or prescription drugs (redetermination). You need to appeal within 60 days of the decision. If you have a good reason for being late in appealing, let us know and we will consider whether or not to extend the timeline for appeals. If your health requires it, ask us to give you a “fast appeal”. A fast appeal is called an “expedited reconsideration” (Part C) or an “expedited redetermination” (Part D). To get a fast coverage decision, you must be asking for coverage for medical care or a drug you have not yet received. You can also get a fast coverage decision if it is determined that using the standard deadlines could cause serious harm to your health or hurt your ability to function.
How to file an appeal:
- You may file an expedited (fast) appeal by calling us at 1-877-935-8022 for HMO SNP members, or 1-844-293-2636 for HMO members. TTY/TDD users call 711. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m.
- You may fax your standard or expedited appeal to us at 1-844-273-2671.
- You may appeal by sending us a letter or the plan form provided in the link below – mail to:
Sunshine Health Medicare Advantage
Attn: Appeals and Grievances/Medicare Operations
7700 Forsyth Blvd
Saint Louis, MO 63105
If you want someone else to file your appeal on your behalf – provide us with an Appointment of Representative Form or legal document showing that you have chosen someone other than yourself to file for you and that this person has your permission to see all information including medical records about the appeal. More information and instructions for the Appointment of Representative Form are located in the Appeals and Grievances tab.
As a courtesy, you can utilize the plan form to file an appeal. Please note that you must submit a standard appeal in writing and you have the option of submitting an expedited appeal in writing. The timeframe for a decision on your appeal will start when we receive your request at the plan.
For process or status questions, you can contact us at Member Services 1-877-935-8022 for HMO SNP members, 1-844-293-2636 for HMO members, or TTY/TDD users 711. For process or status questions, your provider can contact us at 1-877-935-8022.
What do we do when you file an appeal?
We will have a different doctor review your case to decide whether or not we should change our decision. We may ask for additional information from you or your doctor if needed. There are also specific timelines we must follow depending on what you ask for and how soon you may need that decision. We will process your appeal as fast as your health status and circumstances require, but no later than:
Medical Decisions (Part C) – Standard Process 30 days; Expedited Process 72 hours
Payment Decisions (Part C) – 60 days
Click here for the Part C Organization Determinations/Appeals Process Chart
Prescription Drug (Part D) – Standard Process 7 days
Prescription Drug (Part D) – Expedited Process 72 hours
Payment Decisions (Part D) – 7 days
Click here for the Request for a Coverage Determination Process Chart
How do non-contracted providers file a claim appeal?
In accordance with the requirements established by the Centers for Medicare and Medicaid Services (CMS), non-contracted providers have Medicare appeal rights. Medicare appeal rights apply to any claim for which we have denied payment.
- All requests for payment appeals must include a completed and signed Waiver of Liability (WOL) statement.
- The appeals process cannot begin until a completed and signed WOL is received.
- Requests for appeals that do not include a WOL, or for which a WOL is not received within the required timeframes, will be issued a Notice of Dismissal of Appeal Request.
- Requests for payment appeals must be filed within 60 calendar days of the explanation of payment (EOP).
- A copy of the EOP and any other supporting documentation (such as medical records when applicable) must be submitted with the appeal request.
- We will make a decision regarding the appeal within 60 calendar days from the date the appeal request was received with the completed Waiver of Liability.
Non-Contracted Provider Appeal Requests should be submitted, with the completed WOL, to the following address:
Sunshine Health Medicare Advantage
Grievance and Appeals – Medicare Operations
P.O. Box 4000
Farmington, MO 63640-3822
Last Updated: 09302016