Appeals

Important information about your appeal rights

If you don't agree with a decision we make about Medicare or Healthy Connections Medicaid services or payment, you have the right to appeal to First Choice VIP Care Plus (Medicare-Medicaid Plan).

How soon must you file an appeal?

If you don't agree with a decision we make about services or payment, you have the right to appeal to First Choice VIP Care Plus. You must file the appeal request within 60 days of the date on your denial notice for medical services or drugs. You may file your request by mail, fax, or phone. We may give you more time to file if you have a good reason. You can look at your Member Handbook, Chapter 9 (PDF) for more information on how to file an appeal. You can also contact Member Services.

There are two kinds of appeals related to Medical Services and Non-Medicare covered drugs:

1. Standard appeal: You have the right to appeal if you don't agree with a decision we make about services or payment. We will review our decision and let you know what we decide. We must give you an answer within 30 calendar days after we get your appeal. Our decision might take longer if you ask for an extension or if we need more information about your case. We will tell you if we're taking extra time and will explain why more time is needed. If your appeal is for payment of a service you have already received, we will give you a written answer within 60 calendar days.
2. Fast appeal: You will get an answer within 72 hours after we get your fast appeal. You can ask for a fast appeal if you or your doctor believe your health could be harmed by waiting up to 15 calendar days for a decision.

There are two kinds of appeals related to Part D and Part B drugs:

1. Standard appeal: You have the right to appeal if you don't agree with a decision we make about services or payment. We will review our decision and let you know what we decide. You will get a written answer on a standard appeal seven calendar days after we get your appeal. If your appeal is for reimbursement of a drug you have already received, we will give you a written answer within 14 calendar days.
2. Fast appeal: You will get an answer within 72 hours after we get your fast appeal. You can ask for a fast appeal if you or your doctor believe your health could be harmed by waiting up to seven calendar days for a decision.

We will give you a fast appeal if a doctor asks for one for you or supports your request. If you ask for a fast appeal without support from a doctor, we will decide if your request requires a fast appeal. If we don't give you a fast appeal, we'll give you an answer within 30 calendar days.

How to ask for an appeal with First Choice VIP Care Plus:

Step 1: You, your representative, or your provider must ask us for an appeal within 60 days of the date on your denial notice for a service authorization. Your appeal request must include your:

• Name.
• Address.
• Member ID number.
• Reasons for appealing and services that you want to appeal.
• The date you received the service or plan to receive the service.
• Evidence you want us to review to make our decision, such as medical records, a letter from your provider, or other information that explains why you need the item or service. You may call your provider for this information.
• You can also use the Appeal Request Form (PDF) or the Request for Redetermination of Medicare Prescription Drug Denial to file an appeal with First Choice VIP Care Plus.
• If your request is made by a family member, friend, or other party, the appeal requests must include a filled-out Appointment of Representative Form (PDF) or an equivalent written notice. Follow these instructions for completing the Appointment of Representative Form.

Step 2: You have choices about how to appeal: call us, or mail or fax your appeal request.

Call us at: 1-888-978-0862 (TTY/TDD 711) or fax your request to 1-855-221-0046.

If you ask for an appeal by phone, we will send you a letter confirming what you told us.

Or mail your appeal request to:
First Choice VIP Care Plus
Attn: Appeals Department
P.O. Box 80109
London, KY 40742-0109

Please Note: If you would like to continue receiving previously approved services that have been reduced or terminated, please make sure you request an appeal within ten (10) calendar days of the decision that you are appealing.

How to obtain an aggregate number of grievances, appeals and exceptions filed with First Choice VIP Care Plus:

To obtain an aggregate number of First Choice VIP Care Plus grievances, appeals and exceptions, please call Member Services at 1-888-978-0862 (TTY/TDD 711) from 8 a.m. to 8 p.m., 7 days a week.

For process or status questions, call Member Services at 1-888-978-0862 (TTY/TDD 711), 8 a.m. - 8 p.m., 7 days a week.

For help with complaints, grievances, and information requests, you can also call the Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (TTY 1-877-486-2048).Or go to the Medicare website and fill out a Medicare Complaint Form. (Please note: by clicking on this link you will be leaving the AmeriHealth Caritas VIP Care Plus website.)