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Coverage Decisions and Appeals

Part C Coverage Decisions (Organization/Coverage Determinations) and Appeals

Some covered services require prior authorization (approval in advance) before you receive them or in order to be able to continue receiving them. Asking for approval of a treatment or service is called a service authorization request. You, your health care provider or someone you trust can ask for this. Your health care provider should follow our process for submitting a service authorization request.  Our decision is called a coverage determination. There are items and services that require the plan’s authorization before you receive the service. Please review your Evidence of Coverage to confirm if the service requires prior authorization. Failure to receive an authorization before receiving the item or service could result in the denial of payment for the service rendered. The notice of our decision to deny a service authorization request or to approve it for an amount that is less than requested is called an Initial Adverse Determination.

There is a process for requesting an appeal of an Initial Adverse Determination or to appeal a problem related to your benefits and coverage for medical services and prescription drugs, including problems related to payment. This is the process you use for issues regarding coverage or the way in which something is covered.

Asking for a coverage decision

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases, we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who make the original unfavorable decision. When we have completed the review, we give you our decision.

You, an independent organization that is not connected with our plan (State Health Insurance Assistance Program), doctor or other prescriber, someone else to act on your behalf or your lawyer may ask us for a coverage decision or appeal a decision. If you want someone other than yourself to be your representative, you need to complete the Appointment of Representative form that gives that person permission to act on your behalf. You must give us a copy of the signed form.

Appointment of Representative Form: English (PDF)  Spanish (PDF) 

When to ask for a Coverage Decision for Medical Services (Part C)

Ask for a medical coverage decision if any of the following situations applies to you: 

  1. You are not getting certain medical care you want and you believe that this care is covered by our plan.
  2. Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan.
  3. You have received medical care or services that you believe should be covered by the plan, but we have said we will not pay for this care.
  4. You have received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care.
  5. You are being told that coverage for certain medical care you have been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.

You can ask for a decision about Part C (medical care) coverage on one of the following ways:

  • Call Us - 1-800-960-2530 (TTY 1-877-247-6272) Monday - Friday, 8 a.m. to 6 p.m.
  • Fax: 1-813-262-2802
  • Write:
    • Wellcare, Coverage Determinations- Medical
      P.O. Box 31370
      Tampa, FL 33631
      (Appeals about claim payments must be submitted in writing)

How to make an appeal?

To start your appeal, you, your doctor or your representative must contact our plan. If a representative is appealing on your behalf, you must provide your consent for us to review the appeal. If you are asking for a fast appeal, you may make your appeal in writing or you may call us. You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you of our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. You may submit, or the Plan may ask for additional information to complete your appeal. If you are asking for an expedited appeal, the timeframe to submit additional information is limited.

If requesting coverage for a service and your health requires it, ask for a "fast appeal." If we are using the fast deadlines, we must give you our respond within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it. If we are using the standard deadlines, we must give you our answer within 30 days for Medical Services (Part C) related appeals. If your standard request is about Part B covered services, we must respond within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for "fast" appeal. We or you can also ask for a 14 day extension.

If your request is about a claim payment, you must send us a written appeal. We must respond to a request for payment appeal in 60 calendar days.

There are three ways to file an appeal for Part B & C Determinations:

  • Call Us: 1-800-960-2530 (TTY 1-877-247-6272Monday - Friday, 8 a.m. to 6 p.m. (Appeals of Authorizations Only)
  • Fax: 1-866-201-0657
  • Write:
    • Wellcare, Appeals Department
      P.O. Box 31368
      Tampa, FL 33631-3368
  • Overnight Address:
    Wellcare, Appeals Department
    8735 Henderson Road, Ren. 4
    Tampa, FL 33634

Independent Review Organizations; also known as Independent Review Entity (IRE)

If our plan says no to your appeal, your appeal will automatically be forwarded for a Level 2 appeal with the Independent Review Organization called Maximus Federal Service. This organization decides whether the decision we made should be changed. The Independent Review Organization an independent organization that is hired by Medicare.

    Redeterminations (Part D Appeals)

    If we deny your request for a coverage determination (exception), or a payment for a drug, you, your doctor, or your representative may ask us for a redetermination. You have 60 days from the date of our coverage denial letter to request a redetermination. You can complete the Redetermination form, but you do not have to use it.

    You can ask for a drug coverage redetermination one of the following ways:

    An expedited redetermination (Part D appeal) request can also be made by phone at Contact Us.

    If you or your doctor states that waiting 7 days for a standard decision could seriously harm your health or ability to regain maximum function, you can ask for a fast (expedited) decision. If your doctor states this, we will automatically give you a decision within 72 hours. If we do not receive your doctor’s supporting statement for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

    For more information about coverage determinations (exceptions) and redeterminations (Part D appeals), please refer to your Evidence of Coverage (EOC).

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    Y0020_WCM_100876E Last Updated On: 10/1/2022