This is a summary of the process and contact information for Coverage Decisions, Complaints, Appeals & Grievances with Virginia Premier. Many issues or concerns can be promptly resolved by calling Member Services at 1-877-739-1370 (TTY: 711). From October 1 to February 14, we are open daily from 8:00 am to 8:00 pm, 7 days a week, excluding certain holidays. On weekends and certain holidays from February 15 to September 30, your call will be handled by our automated phone system. If you have not already done so, you may want to first contact Member Services before submitting one of the forms below. Complete information about Coverage Decisions, Complaints, Appeals and Grievances can be found in your plan's Evidence of Coverage.
A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or Part B drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay.
If you or your doctor are not sure if a service, item, or Part B drug is covered by Virginia Premier, either of you can ask for a coverage decision before the doctor gives the service, item, or Part B drug. Sometimes a coverage decision is also called an organization determination.
How can I file a coverage decision to get a medical, behavioral health or long-term care service or Part B drug?
To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a decision.
How long does it take to get a coverage decision?
Once we receive your request, it usually takes up to 14 calendar days after you asked. If we don't give you our decision within 14 calendar days, you can appeal. Making an appeal means asking us to review our decision. Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days.
Can I get a coverage decision faster?
Yes. If you need a response faster because of your health, you should ask us to make a "fast coverage decision." If we approve the request, we will notify you of our decision within 72 hours.
Asking for a fast coverage decision:
If you request a fast coverage decision, start by calling, writing, or faxing our plan to ask us to cover the care you want. You can call us at 1-877-739-1370 (TTY: 711). You can also have your doctor or your representative call us.
You must meet the following two requirements to get a fast coverage decision:
If your doctor says that you need a fast coverage decision, we will automatically give you one.
If you ask for a fast coverage decision, without your doctor's support, we will decide if you get a fast coverage decision. Please see your plan's Evidence of Coverage for additional information.
If the coverage decision is Yes, when will I get the service or item?
You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period.
If the coverage decision is No, how will I find out?
If the answer is No, we will send you a letter telling you our reasons for saying no. If we say no, you have the right to ask us to reconsider – and change – this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process.
Coverage Determination for a Part D drug
A Coverage Determination is a decision about whether a Part D drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. For more information, check your plan's Evidence of Coverage.
A member, member representative or prescribing physician can request to initiate a coverage determination. You can request it by either:
If your coverage determination is denied for your Part D drug, you may request a redetermination. Visit your plan's Evidence of Coverage for more information.
How long does it take to get a coverage decision for Part D drugs?
We will give you an answer on a standard coverage decision within 72 hours. We will give you an answer on reimbursing you for a Part D drug you already paid for within 14 calendar days.
An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. For example, we might decide that a service, item, or Part D drug that you want is not covered or is no longer covered by Virginia Premier. If you or your doctor disagree with our decision, you can appeal.
How do I file an appeal?
To start your appeal, you, your doctor or other provider, or your representative must contact us in writing or by phone.
Can someone else make the appeal for me?
Yes. Your doctor or other provider can make the appeal for you. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative form. The form gives the other person permission to act for you. You can download an Appointment of Representative form, call Member Services and ask for one, or visit the Medicare website . The form will give the person permission to act for you. You must give us a copy of the signed form. If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal.
How much time do I have to make an appeal?
You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of a good reason are: you had a serious illness, or we gave you the wrong information about the deadline for requesting an appeal.
Can my doctor give you more information about my appeal?
Yes, you and your doctor may give us more information to support your appeal.
When will I hear about a "standard" appeal decision?
If your appeal is about:
When will I hear about a "fast" appeal decision?
If your appeal is about:
If our answer is yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal.
If our answer is no to part or all of what you asked for, we will send you a letter. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens. You can see your plan’s Evidence of Coverage for more information.
How can I get an aggregate number of grievances, appeals, and exceptions filed with Virginia Premier?
Please call us at 1-877-739-1370 (TTY: 711).
A grievance is a complaint and does not involve a request for payment, a request for authorization for services or a request for an appeal of denied services by Virginia Premier. For example, you would file a grievance if:
How to file a complaint (grievance)
Call Member Services at 1-877-739-1370 (TTY: 711). The complaint must be made within 60 calendar days after you had the problem you want to complain about. If there is anything else you need to do, Member Services will tell you.
If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast complaint" and respond to your complaint within 24 hours.
If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
You can also send your complaint to Medicare. Medicare takes your complaints seriously and will use this information to help improve the quality of the of the Medicare program. Please feel free to call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. The call is free. In lieu of calling, you can also find the Medicare Complaint Form online.
If Help is Needed
You can ask any of these people for help regarding coverage decisions or making an appeal: