The prescription drug standard appeals (redetermination) process
The appeals process, also referred to as a redetermination process, is used to review an adverse coverage determination made by Security Health Plan on the benefits that you believe the patient is entitled to receive. This includes a delay in providing or approving drug coverage (when the delay will affect your health), or on any amounts you must pay for drug coverage. The following information provides a detailed description of the appeals process.
There are two kinds of appeals you can file:
Standard (7 days) – You can ask for a standard appeal. We must give you a decision no later than 7 calendar days after we receive the appeal. If we fail to meet the 7-day deadline, we will automatically forward the appeal to an IRE. This is a reviewer outside Security Health Plan.
Fast (72-hour review) – You can ask for a fast appeal if the patient’s health could be seriously harmed by waiting too long for a decision.
- If the provider asks for a fast appeal and indicates that waiting for 7 days could seriously harm the patient’s health, we will automatically give a fast appeal.
- If the member asks for a fast appeal without support from a provider, we will decide if the member’s health requires a fast appeal. If we do not give a fast appeal, we will decide the appeal within 7 calendar days.
We must decide on a fast appeal no later than 72 hours after we get the appeal. If we fail to meet the 72-hour deadline, we will automatically forward your appeal to the IRE.
What do you include with your appeal?
You should include patient’s name, address, identification number, reasons for appealing and any evidence you wish to attach. You may send in supporting medical records, letters or other information that explains why we should provide the service.
How do you file an appeal?
For a standard appeal, you or your authorized representative should mail or deliver your written appeal to the address below:
Security Health Plan
Attn: Medicare Pharmacy Appeals
1515 North Saint Joseph Avenue
P.O. Box 8000
Marshfield, WI 54449-8000
Providers or their agent(s) also may initiate requests for standard appeals via:
- Security Health Plan Pharmacy request line at 1-877-873-5611 or 715-221-9604
- Security Health Plan Pharmacy fax number at 715-221-9989
- Security Health Online (requires login with user name and password)
For a fast appeal, call us at 1-877-873-5611 or fax us at 715-221-9989.
What happens next?
After we receive the written appeal, we will review our decision. If we continue to deny any of the prescription services requested and you disagree with that decision, there are further appeal rights. You have 60 days to file a written appeal with the IRE. Please contact Security Health Plan at 1-877-873-5611 for information regarding the IRE. If you disagree with the IRE decision, there are additional appeal rights. You will be notified of these appeal rights if this happens.