MCS Classicare Procedure for Handling Part D Redetermination and Reconsideration

Coverage Redeterminations (appeals processes)

If a Part D plan sponsor issues an adverse coverage determination, the enrollee may appeal the decision to the plan sponsor by requesting a redetermination. An enrollee or an enrollee's appointed representative may request a standard or expedited redetermination.

An enrollee's prescribing physician may request an expedited redetermination on an enrollee's behalf. If the enrollee's physician is also the enrollee's appointed representative, he or she may also request a standard redetermination.

To learn more about how to request an exception, refer to your product Evidence of Coverage as described below:

– See the Evidence of Coverage, Chapter 9 under “What to do if you have a problem or complaint (coverage decisions, appeals, complaints)”

For information about appointing a representative, see Appointment of Representative

How to Request a Redetermination?

Redetermination requests must be filled with the plan sponsor within 65 calendar days from the date of the denial notice of the coverage determination.

• Expedited redeterminations may be made orally or in writing
• Standard redeterminations may be submitted orally or in writing

To fill the requested information, you may use our redetermination of Medicare Prescription Drug Denial Redetermination Request Form:

How a Plan Sponsor Processes Redetermination Requests?

Once the request is received by the plan sponsor, it must make its decision and notify the enrollee of its decision as quickly as the enrollee's health requires, but no later than 72 hours for expedited requests or 7 calendar days for standard requests after receiving the request.

If the redetermination decision is unfavorable, the notice the enrollees receive will contain the information an enrollee needs to file a request for a reconsideration with the Independent Review Entity (IRE).

If the member participates in the Drug Management Program (DMP) and wishes to appeal the decision about their access to opioid medications, an at-risk determination is subject to the same Part D benefit appeal process and timeframes mentioned above. If the redetermination decision is unfavorable, MCS Classicare will forward the case to the Independent Review Entity within 24 hours.

Disclosure of Grievances and Appeals Data upon Request

MCS Classicare beneficiaries have the right to request the number of grievances and appeals received by the Plan. The information will include aggregated number of grievances and appeals received and their disposition.

How to obtain an aggregate number of grievances, appeals, and exceptions filed with MCS Classicare?

As a member of our plan, you have the right to get several kinds of information from us. This includes information about the number of grievances and appeals made by members and the plan’s performance ratings, including how it has been rated by plan members and how it compares to other Medicare Advantage health plans. If you want any of the following kind of information, please call our Service Call Center at 787-620-2530 (Metro area), 1-866-627-8183 (toll free number) or TTY 1-866-627-8182 (people with hearing disabilities). Our service hours are Monday to Sunday from 8:00 a.m. at 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m. Also, you can request it by fax at 787-620-7765 or by mailing: MCS Advantage, Inc., Department of Grievances and Appeals, PO Box 195429 San Juan PR 00919-5429.

Part D late enrollment penalty (LEP) reconsideration

If MCS Classicare has notified you that your new premium will include a penalty for late enrollment in Medicare Part D, and you don’t agree with the penalty, you can ask Medicare to reconsider its decision if certain circumstances apply to you. For example, you might disagree with the penalty if you had Extra Help from Medicare to pay for your prescription drug coverage or if you didn't get a notice that clearly explained whether you had creditable coverage.

You should submit a request for reconsideration within 60 days from the date of receipt of the LEP letter to the address provided on the Part D late enrollment penalty reconsideration request form, or Medicare may not consider your request.

The LEP reconsideration request form must be completed and signed. Include copies of information you believe may help your case (like information about previous creditable prescription drug coverage). If you have named someone to act for you, include a copy of proof that the person can represent you. Proof could be a power of attorney, a court order, or an Appointment of Representative form.

If you have questions or if you would like more information about the late enrollment penalty, call MCS Classicare at 787-620-2530 (Metro) or 1-866-627-8183 (toll free). TTY users can call 1-866-627-8182. You can also get information by visiting www.medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.