The initial determination we make is the starting point for dealing with requests you may have about covering a Part D drug and/or Part C medical care or service you need, or paying for a Part D drug and/or Part C medical care or service you already received. Initial decisions about Part D drugs are called "coverage determinations." Initial decisions about Part C medical care or services are called "organization determinations." With this decision, we explain whether we will provide the Part D drug and/or Part C medical care or services you are requesting or pay for the Part D drug and/or Part C medical care or services you already received.
The following are examples of requests for initial determinations:
- You ask us to pay for a prescription drug you have received.
- You ask for a Part D drug that is not on your plan sponsor's list of covered drugs (called a formulary). This is a request for a formulary exception. See "What is an exception?" below for more information about the exception process.
- You ask for an exception to our utilization management tools, such as prior authorization, dosage limits, quantity limits, or step therapy requirements. Requesting an exception to a utilization management tool is a type of formulary exception. See "What is an exception?" below for more information about the exception process.
- You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a tiering exception. See "What is an exception?" below for more information about the exception process.
- You ask us to pay you back for the cost of the drug you bought at an out-of-network pharmacy. In certain circumstances, out-of-network purchases, including drugs provided to you in a physician's office, will be covered by the Plan.
- You are not getting Part C medical care or services you want, and you believe that this care is covered by the Plan.
- We will not approve the medical treatment your doctor or other medical provider wants to give you, and you believe that this treatment is covered by the Plan.
- You are being told that a medical treatment or service you have been getting will be reduced or stopped, and you believe that this could harm your health.
- You have received Part C medical care or services that you believe should be covered by the Plan, but we have refused to pay for this care.
What is an exception?
An exception is a type of initial determination (also called a coverage determination) involving a Part D drug. You or your doctor may ask us to make an exception to our Part D coverage rules in a number of situations.
- You may ask us to cover your Part D drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan.
- You may ask us to waive coverage restrictions or limits on your Part D drug. For example, for certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
- You may ask us to provide a higher level of coverage for your Part D drug. If your Part D drug is continued in our non-preferred brand (Tier 3) tier, you may ask us to cover it at the cost-sharing amount that applies to drugs and the preferred brand (Tier 2) tier instead. This would lower the coinsurance/co-payment amount you must pay for your Part D drug. Please note if we grant your request to cover a Part D drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for Part D drugs that are in the specialty (Tier 4) tier.
Who may ask for an initial determination?
You, your prescribing physician, or someone you name may ask us for an initial determination. The person you name would be your appointed representative. You may name a relative, friend, advocate, doctor or anyone else to act for you. Other persons may already be authorized under state law to act for you. If you want someone to act for you who is not already authorized under state law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative.
If you are requesting Part C medical care or services, this statement must be sent to us at the address or fax number listed under
"Part C Organization Determinations." If you are requesting Part D drugs, this statement must be sent to us at the address or fax number listed under "Part D Coverage Determinations."
The Appointment of Representation form can be found below. This form gives the person legal permission to act as your appointed representative. This statement must be faxed or mailed to us at the designated number or address below.
Appointment of Representation Form
Upon receipt of all the necessary information needed to review an initial determination, standard initial determination decisions will be made within 72 hours. Fast initial determination decisions will be made within 24 hours.
To begin an initial determination request, please call Customer Service at 1-866-207-6301 (TTD/TTY users, call 1-866-239-6265) seven days a week, 8:00 a.m. - 2:00 a.m. Eastern.
The forms below can be used to request an initial determination by mail or fax.
WellCare Medicare Coverage Determination Request Form
WellCare Injectable Infusion Form
Medicare Part D Coverage Determination Request Form
An initial determination request can be mailed to:
WellCare Health Plans Attention:
Pharmacy Department
P.O. Box 31577
Tampa , FL 33631-3577
You can fax an initial determination request to 1-866-388-1767.
Please click here to access the Evidence of Coverage for more detailed information on all appeals and grievance policies.
To learn more about the importance of reporting adverse events, product problems and product use errors, please visit FDA Medwatch Reporting.
Appeal Level 1: Appeal to the Plan
An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services and/or prescription drugs or payment for services and/or prescription drugs you already received.
You may ask us to review our initial determination, even if only part of our decision is not what you requested. An appeal to the plan about a Part D drug is also called a plan "redetermination." An appeal to the plan about Part C medical care or services
is also called a plan "reconsideration." When we receive your request to review the initial determination, we give the request to people at our organization who are not involved in making the initial determination. This helps ensure that we will give your request a fresh look.
If you are appealing an initial decision about a Part D drug, you or your representative may file a standard appeal request, or you, your representative, or your doctor may file a fast appeal request. Please see "Who may ask for an initial determination?" above, for information about appointing a representative.
If you are appealing an initial decision about Part C medical care or services, the rules about who may file an appeal are the same as the rules about who may ask for an organization determination. Follow the instructions under “Who may ask for an initial determination?” However, providers who do not have a contract with the Plan may also appeal a payment decision as long as the provider signs a “waiver of payment” statement saying it will not ask you to pay for the Part C medical care or service under review, regardless of the outcome of the appeal.
You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.
How to file your appeal:
- Asking for a standard appeal – To ask for a standard appeal about your Part D drug and/or Part C medical care, a signed, written appeal request must be sent to the address listed below.
You may also ask for a standard appeal by calling us at the phone number listed below. We will give you our decision within 7 calendar days of receiving the appeal request. - Asking for a fast appeal – If you are appealing a decision we made about giving you a Part D drug and/or Part C medical care that you have not yet received, you and/or your doctor will need to decide if you need a fast appeal. The rules about asking for a fast appeal are the same as the rules for asking for a fast initial determination. You, your doctor, or your representative may ask us for a fast appeal by calling or writing to the numbers or address listed below. We will give you our decision within 72 hours after we receiving the appeal request.
Be sure to ask for a "fast" or "expedited" review. Remember, if your doctor provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically give you a fast appeal. If you ask for a fast 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 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. The letter will also tell you how to file a “fast grievance” if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast appeal, we will give you a standard appeal.
To file an appeal, you, your representative, or your doctor can contact Customer Service at 1-866-207-6301 (TTD/TTY users, call 1-866-239-6265) seven days a week, 8:00 a.m. - 2:00 a.m. Eastern, or a written request can be delivered to:
WellCare Health Plans
Attention Appeals
P.O. Box 31368
Tampa , FL 33631
If you, your appointed representative, or prescribing physician would like to file an appeal via fax, please fax the request to 1-813-262-2907.
The following forms may be used to request an appeal.
WellCare Medicare Redetermination Request Form
WellCare Provider/Physician Appeal Form
Please click here to access the Evidence of Coverage for more detailed information on all appeals and grievance policies.
Appeal Level 2: Independent Review Entity (IRE)
At the second level of appeal, your appeal is reviewed by an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this entity.
If you asked for Part D drugs or payment for Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the IRE. If you choose to appeal you must send the appeal request to the IRE. The decision you receive from the plan (Appeal Level 1) will tell you how to file this appeal, including who can file the appeal and how soon it must be filed.
If you asked for Part C medical care or services, or payment for Part C medical care or services, and we did not rule completely in your favor at Appeal Level 1, your appeal is automatically sent to the IRE.
You must make a request for review by the IRE in writing within 60 calendar days after the date you were notified of the decision on your first appeal. The IRE has the same amount of time to make its decision as the plan had at Appeal Level 1.
If the IRE decides completely in your favor:
The IRE will tell you in writing about its decision and the reasons for it.
- For a decision to pay you back for a Part D drug you have already paid for and received, we must send payment to you within 30 calendar days from the date we receive notice reversing our decision.
- For a standard decision about a Part D drug you have not yet received, we must cover the Part D drug you asked for within 72 hours after we receive notice reversing our decision.
- For a fast decision about a Part D drug you have not yet received, we must cover the Part D drug you asked for within 24 hours after we receive notice reversing our decision.
- For a decision about payment for Part C medical care or services you already received. We must pay within 30 days after we receive notice reversing our decision.
- For a standard decision about Part C medical care or services you have not yet received. We must authorize your requested Part C medical care or service within 72 hours, or provide it to you within 14 days after we receive notice reversing our decision.
- For a fast decision about Part C medical care or services. 48 We must authorize or provide your requested Part C medical care or services within 72 hours after we receive notice reversing our decision.
You must send your written request to the Independent Review Entity whose name and address is included in the redetermination notice and on the form below.
Medicare Reconsideration Request Form
Please click here to access the Evidence of Coverage for more detailed information on all appeals and grievance policies.
Grievances
A grievance is any complaint, other than one that involves a request for an initial determination or an appeal as described above.
Grievances do not involve problems related to approving or paying for Part D drugs, Part C medical care or services, problems about having to leave the hospital too soon, and problems about having Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending too soon.
Who may file a grievance?
You or someone you name may file a grievance. The person you name would be your representative. You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the court or in accordance with state law to act for you. If you want someone to act for you who is not already authorized by the court or under state law, then you and that person must sign and date a statement that gives the person legal permission to be your representative.
The Appointment of Representation form can be found below. This form gives the person legal permission to act as your appointed representative. This statement must be faxed or mailed to us at the designated number or address. This completed form must be included with each grievance.
Appointment of Representation Form
If you have concerns or problems related to your prescription drug coverage and/or medical care, we encourage you to contact us. We will try to resolve any complaint by phone. Please call Customer Service at 1-866-207-6301 (TTD/TTY users, call 1-866-239-6265) seven days a week, 8:00 a.m. - 2:00 a.m. Eastern.
You may also send your complaint in writing to:
WellCare Grievance Department
PO Box 31384
Tampa, FL 33631-3384
Grievances can be faxed to: 1-866-388-1769.
A standard grievance is resolved within 30 days from the date of submission. A grievance can be submitted by telephone or in writing by mailing your request to the address listed above.
An expedited grievance can be submitted by calling 1-866-207-6301 (TTY/TTD users call 1-866-239-6265) seven days a week, 8:00 a.m. - 2:00 a.m. Eastern. An expedited grievance is resolved within 24 hours. A grievance coordinator will contact you and/or your representative with a resolution.
The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.
Please click here to access the Evidence of Coverage for more detailed information on all appeals and grievance policies.
