2024 Part D Appeals & Grievances

PART D APPEALS

If you disagree with the outcome of a coverage determination, you, your Appointed Representative, or your prescribing physician may file an appeal called a plan “redetermination”. You must ask for it within 60 days from the date of our denial notice, unless you can show good cause for delay. Please refer to your Evidence of Coverage located on the 2024 Plan Documents page that discusses the five (5) levels of appeals. When our plan is reviewing your appeal, we take another careful look at all the information about your initial coverage request. You also have the right to give us new information supporting your appeal request. We also reevaluate if we were being fair and following all the rules when we said no to your initial request. We may contact you or your doctor or other prescriber to get more information.

How to request a Part D appeal

You or your Appointed Representative (your doctor, attorney, advocate, relative, friend, or other person authorized to act on your behalf) can submit an online Part D appeal request, fax, or mail a request for a standard redetermination.

• ONLINE: To submit your Part D appeal request online, please click here.
• FAX: To fax your Part D appeal request, complete the correct coverage determination request form and fax to RxAdvance at 866-836-8043. These forms can be found on the Formulary Restrictions page. If you’re not sure which form to use, you can complete a general request form called the Request for Medicare Prescription Drug Coverage Determination Form (Coming soon).
• MAIL: Please complete the correct coverage determination request form which can be found on the Formulary Restrictions page. If you’re not sure which form to use, you can complete a general request form called the Request for Medicare Prescription Drug Coverage Determination Form (Coming soon). Once completed, mail your coverage determination request to:

RxAdvance/HealthTeam Advantage
Attn: Part D Coverage Determinations
PO BOX 504
Southborough, MA 01772

• PHONE: To file an expedited Part D appeal request by phone
  HealthTeam Advantage Plan I and Plan II PPO members call RxAdvance at 1-800-237-1992
  HealthTeam Advantage Diabetes & Heart Care HMO members call RxAdvance at 1-800-459-0984

PLEASE NOTE: Those not authorized, under state law, to act for you must first sign an Appointment of Representative form and either fax to RxAdvance at 866-634-7622 or mail it to the address below:

RxAdvance/HealthTeam Advantage
Attn: Member/Pharmacy Services
PO BOX 504
Southborough, MA 01772

How long it takes for a Part D appeal decision

A standard appeal decision will be made within seven calendar days. If our decision is fully in your favor, we must authorize the service within seven days and/or make the payment within 14 calendar days.

If waiting for a standard decision could seriously harm your health or compromise your ability to regain maximum function, you or your prescribing doctor may request an expedited appeal for a decision within 72 hours. This process does not apply to denied claims for payment.

Status requests

For questions regarding the process or status of a Part D appeal request, you, your physician, or your appointed representative should call:

HealthTeam Advantage Plan I and Plan II PPO members call RxAdvance at 1-800-237-1992 (TTY:711)

HealthTeam  Advantage Diabetes & Heart Care HMO members call RxAdvance at 1-800-459-0984 (TTY:711)

PART D GRIEVANCES

A grievance is any dispute other than one that involves a coverage determination that expresses dissatisfaction with the operations, activities or behavior of HealthTeam Advantage or one of our providers. For example, a grievance can involve the behavior of a network pharmacist, the ability to get the information you need from a customer service representative, or the condition of a network pharmacy.

You must file a grievance within 60 days from the date of the event that led to the complaint. Expedited or fast grievances will be responded to within 24 hours if the grievance is related to the plan’s refusal to make a fast coverage determination or redetermination and you haven’t purchased or received the drug. We’ll address other grievance requests within 30 days after receiving your complaint. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days to answer your complaint.

How to file a Part D Grievance

• PHONE/VERBAL: If you’d like to file a verbal grievance by phone, HealthTeam Advantage Plan I and Plan II PPO members call 1-800-237-1992 (TTY: 711); HealthTeam Advantage Diabetes & Heart Care HMO members call 1-800-459-0984 (TTY:711).
  If you request a written response to your phone complaint, we’ll respond in writing.
• WRITTEN: If you’d like to file a written grievance, please send to one of the following:
  • Fax: 866-836-8043
  • Mail:
    RxAdvance/HealthTeam Advantage
    Attn: Appeals & Grievances
    PO BOX 504
    Southborough, MA 01772

For more information, you can call your HealthTeam Advantage Healthcare Concierge at 1-888-965-1965 (TTY:711).

Status requests

For questions regarding the process or status of a Part D appeal request, you, your physician or your appointed representative should call:

HealthTeam Advantage Plan I and Plan II PPO members call RxAdvance at 1-800-237-1992 (TTY:711)

HealthTeam  Advantage Diabetes & Heart Care HMO members call RxAdvance at 1-800-459-0984 (TTY:711)

Complaints and disenrollment

If you have a complaint, you can complain to Medicare. You can also end your enrollment. To do that, refer to the information about disenrollment on the Your Rights page.