Grievances, Appeals and Coverage Determinations
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As much as we try to meet your needs, we understand there may be times when you’re dissatisfied with some aspect of your 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.
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.
A request for Clear Spring Health to reconsider a coverage related decision that we made about your 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 prescription drug
An expedited appeal, further described below, is a type of appeal used when the member’s health may be in immediate jeopardy.
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. (NOTE: Clear Spring Health contracts with Express Scripts to administer select Medicare Part D services.)
Phone1 (877) 842-9790;
TTY: 1 (800) 899-2114
Fax1- (614) 907-8547
Note: Member Services is available 24 hours a day, 7 days a week.
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 prescription drug.
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 and/or print the Appeals Form.
Once your appeal is received, 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.
Standard and Expedited Appeals:
Phone1 (844) 374-7377;
TTY: 1 (800) 716-3231
Fax1 (877) 852-4070
Attn: Medicare Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Note: Phone hours are 24 hours a day, 7 days a week.
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.
Please refer to the Evidence of Coverage under Member Plan Documents for more detailed information on the timeframes and other elements associated with the coverage determination process. Or, call Member Services using the phone number on the back of your member I.D. card.
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.
By clicking this link you can review and/or print the Appointment of Representative Form.
Fax1 (855) 231-8777
Miramar, FL 33027
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.
You can also contact the Center for Medicare and Medicaid Services (CMS) at 1-800-Medicare for additional details about the grievance and appeals process. In lieu of calling, you can enter a complaint at Medicare.gov