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Para asistencia en español, llame al:

(877) 364-4566; TTY: 711 y oprima el número 2

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Si llama del 1ro de abril al 30 de septiembre, se usará sistema
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y los días feriados.

Our Contacts

To learn more, please call
1 (877) 364-4566; TTY: 711
Clear Spring Health,

PO Box 278530
Miramar, FL 33027

Hours of Operation

8:00 a.m. – 8:00 p.m., 7 days a week

(Between April 1 – September 30, voicemail will be available on Saturday, Sunday and federal holidays.)

Grievances, Appeals & Coverage Determinations

Home  >  Appeals & Grievances

As much as we try to meet your needs, we understand there may be times when you’re dissatisfied with some aspect of your medical or prescription drug coverage, our service or you need to make a special request. We want to be the first step in addressing your concerns.

 There are three processes available to you: Grievance, Appeal and Coverage Determination.

Grievance

A formal complaint that expresses dissatisfaction with any aspect of Clear Spring Health’s operations, activities, or behaviors of its providers/partners. A grievance is not submitted to dispute a denied claim or service.

Appeal

A request for Clear Spring Health to reconsider a coverage related decision that we made about your medical or prescription drug benefit coverage. Some examples of an appeal include:

  • How a claim was paid, partially denied or denied
  • Denial of a request or authorization for a medical service, medical equipment, or prescription

An expedited appeal, further described below, is a type of appeal used when the member’s health may be in immediate jeopardy.

Coverage Determination

This is the original decision Clear Spring Health (not the pharmacy) makes about your prescription drug benefits. This can be a decision about if your drug is covered, if you met the Clear Spring Health’s requirements to cover the drug, or how much you pay for the drug.

An exception is a type of coverage determination and has multiple forms. Some examples are:

  • Formulary Exception – an exception that allows you to receive a drug that’s not on your selected Clear Spring Health plan’s formulary.
  • Tier Exception – an exception that allows you to receive a non-preferred drug at the lower, preferred tier, cost-sharing level.

Below is information about each process including how and where to submit these requests. More detailed information on each of these processes is available in your Evidence of Coverage or by calling Member Services at the number on the back of your Clear Spring Health I.D. card.

Grievance

A grievance is a complaint about any aspect of your plan—for example, a problem with the service you receive, or you believe our communication or printed documents are difficult to understand. You or your authorized representative can file an oral or written grievance with our plan within 60 calendar days of the event.

Once Clear Spring Health receives your grievance, it will be investigated, and you will be informed of our decision.

You can file a grievance by phone, fax or mail. By clicking this link you can review and/or print the Grievance Form.

Phone

1 (877) 364-4566;
TTY: 711

Fax

1 (866) 235-5181

Mail

Clear Spring Health
Attention: Appeals & Grievances
3601 SW 160th Avenue, Suite 450
Miramar, FL 33027

Note: Member Services is available 8:00 a.m. – 8:00 p.m. (Between April 1 – September 30, 2021, voicemail will be used on Saturday, Sunday and federal holidays.)

Appeal

An appeal is a request for us to reconsider an initial coverage decision that Clear Spring Health has made regarding your medical or prescription drug coverage or payment denial. Examples of reasons for an appeal include:

  • How a claim was paid, partially denied, or denied.
  • Denial of a request or authorization for a medical service, medical equipment, or prescription drug.

Expedited Appeal

If you believe waiting for the appeal decision under the standard timeframe may seriously jeopardize your health and/or ability to regain maximum function, you may request an expedited review, or Expedited Appeal.

You, your doctor, your pharmacist (only if related to a prescription drug), or your authorized representative can file an appeal (standard or expedited) by phone, fax or mail. By clicking this link you can review Appeal Form.

Once Clear Spring Health receives your appeal, it will be investigated, and you will be informed of our decision. There are various levels and specific timeframes associated with the appeals and expedited appeals processes. Please refer to the Evidence of Coverage under Member Plan Documents for more detailed information on the timeframes and other elements of the appeals process. Or, call Member Services using the phone number on the back of your member I.D. card.

For medical (or Part C) appeals (standard and expedited):

Phone

1 (877) 364-4566;
TTY: 711

Fax

1 (866) 235-5181

Mail

Clear Spring Health
Attention: Appeals & Grievances 3601 SW 160th Avenue, Suite 450
Miramar, FL 33027

Note: Medical/Part C appeals phone hours are 8:00 a.m. – 8:00 p.m. (Between April 1 – September 30, 2021, voicemail will be used on Saturday, Sunday and federal holidays.)

For prescription drug (or Part D) appeals (standard and expedited):

Phone

1 (877) 842-9791;
TTY: (800) 899-2114

Fax

1 (614) 907-8547

Mail

Express Scripts
Attention: Appeals & Grievance Resolution Team
P.O. Box 3610
Dublin, OH 43016-0307

Note: Prescription Drug/Part D appeals phone hours are 8:00 a.m. – 8:00 p.m., 7 days a week.

Coverage Determination

Coverage determinations and exceptions are specific to prescription drug coverage (regardless if it’s a stand-alone Medicare Part D plan or part of a Medicare Advantage Prescription Drug (MAPD) plan) and are used to ask for an advance approval to cover a prescription drug outside of the Clear Spring Health formulary rules.

You, your doctor, or your authorized representative can request a coverage determination through our secure online portal, phone, fax, or mail. By clicking this link, you can review and/or print the Coverage Determination Form.

You may also submit your request online by using this secure portal.

Phone

1 (844) 374-7377;
TTY: 1 (800) 716-3231

Fax

1 (877) 251-5896

Mail

Express Scripts
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571

Note: Coverage Determination/Exception phone hours are 24 hours a day, 7 days a week

Authorized Representative

You may choose to select an authorized representative to assist or handle affairs related to your health care services. This may be someone you designate as a Power of Attorney, a family member, friend, caregiver, or an advocate you assign and is required to be on file with Clear Spring Health prior to the submission of a grievance, appeal or coverage determination.

To assign an authorized representative, complete the Appointment of Representative form, which must be signed by you and by the person you would like to act on your behalf, and submit to Clear Spring Health by fax or mail.

Click here to print or download the Authorization of Representative Form. You may also use Medicare’s website to obtain a Appointment of Representative Form on Medicare’s website at https://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf

Fax

1 (866) 235-5181

Mail

Clear Spring Health
PO Box 278470
Miramar, FL 33027

Additional Information

If you, your authorized representative or your provider have questions about these processes or want to obtain the aggregate number of grievance, appeal or coverage determination requests filed with Clear Spring Health, call Member Services using the phone number on the back of your member I.D. card.