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.

Examples:
• Longevity Health denies your medical service, item or Part B drug in whole or part.
• Longevity Health denies payment of your claim.

Standard Payment Appeals

• An enrollee;
• An enrollee’s representative;
• Non-contract provider (see §50.1.1 for non-contract provider payment appeals);
• The legal representative of a deceased enrollee’s estate.
• Any other provider or entity (other than the MA plan) determined to have an appealable interest in the proceeding.

Standard Pre-Service Appeals

• An enrollee;
• An enrollee’s representative;
• The enrollee’s treating physician acting on behalf of the enrollee* or staff of physician’s office acting on said physician’s behalf (e.g., request is on said physician’s letterhead or otherwise indicates staff is working under the direction of the provider).

Expedited Pre-Service Appeals

• An enrollee;
• An enrollee’s representative;
• Any physician or staff of physician’s office acting on said physician’s behalf (e.g., request is on said physician’s letterhead or otherwise indicates staff is working under the direction of the provider) acting on behalf of the enrollee.

If you wish to appoint someone to file an appeal on your behalf such as a family member, caregiver, or participating provider, you must complete an Appointment of Representation. More information on this requirement can be found here.

• Expedited requests can be made either orally or in writing.

• Standard appeals request must be made in writing.

If a request for an appeal is filed beyond the sixty (60) calendar day time frame, without good cause, Longevity Health  will dismiss your appeal request.

Once the plan receives the request, 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 30 calendar days for standard requests or 60 calendar days for payment requests.

You, your representative, or your treating physician on your behalf can request an expedited (fast) appeal by phone or in writing and a standard appeal in writing directly to us at:

Mail:
Longevity Health Plan
Appeals and Grievances Department
PO Box 21063
Eagan, MN 55121

Fax: 1-833-610-2399

Call us to expedite an appeal:

• Longevity Health Plan of Florida: 1-866-224-9499 (TTY 711)

• Longevity Health Plan of Illinois 1-888-886-9770 (TTY 711)

• Longevity Health Plan of New Jersey 1-888-899-8490 (TTY 711)

• Longevity Health Plan of New York 1-888-885-7337 (TTY 711)

• Longevity Health Plan of North Carolina 1-888-312-5196 (TTY 711)

• Longevity Health Plan of Michigan 1-888-312-8825 (TTY 711)

• Longevity Health Plan of Colorado 1-888-313-3609 (TTY 711)

• Longevity Health Plan of Massachusetts 1-855-969-5876 (TTY 711)

Providers who are submitting more than 50 pages of documentation, please share files via CD (Compact Disc) or USB (Universal Serial Bus) drive.

Yes. If your health requires a quick response, you must ask for a “fast appeal. Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this.

You may file an expedited appeal by calling:

• Longevity Health Plan of Florida: 1-866-224-9499 (TTY 711)

• Longevity Health Plan of Illinois 1-888-886-9770 (TTY 711)

• Longevity Health Plan of New Jersey 1-888-899-8490 (TTY 711)

• Longevity Health Plan of New York 1-888-885-7337 (TTY 711)

• Longevity Health Plan of North Carolina 1-888-312-5196 (TTY 711)

• Longevity Health Plan of Michigan 1-888-312-8825 (TTY 711)

• Longevity Health Plan of Colorado 1-888-313-3609 (TTY 711)

• Longevity Health Plan of Massachusetts 1-855-969-5876 (TTY 711)

If Longevity Health  decides, based on medical criteria, that your situation is “time-sensitive” or if any physician calls or writes in support of your request for an expedited review, Longevity Health  will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request.

We will review your appeal. If any of the services you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by a reviewer outside of Longevity Health . If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.

An organization determination is any determination (i.e. approval or denial) made by a Medicare health plan (e.g., Longevity Health ) regarding:

• Receipt of, or payment for, a managed care item or service;

• The amount a health plan requires an enrollee to pay for an item or service; or

• A limit on the quantity of items or services.

The way you submit an organization redetermination depends on when your service is happening. If you are requesting an organization redetermination:

Before the service is performed: This is considered an authorization request, please contact provider services.

After a service is provided: This is considered a claim so you should follow the procedures above for submitting a claim.

Our plan has fourteen (14) calendar days (for a standard organization determination request) or seventy-two (72) hours (for an expedited request) from the date it gets your request to notify you of its decision.

An enrollee, an enrollee’s representative, or any provider that furnishes, or intends to furnish, services to an enrollee, may request a standard organization determination by filing an oral or written request with Longevity Health . Expedited requests may be requested by an enrollee, an enrollee’s representative, or any physician, regardless of whether the physician is affiliated with Longevity Health .

An organization determination made by Longevity Health  can be requested with respect to any of the following:

• Payment for temporarily out of the area renal dialysis services, emergency services, post-stabilization care, or urgently needed services

• Payment for any other health services furnished by a provider other than Longevity Health  that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the Longevity Health.

• Longevity Health’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by Longevity Health.

• Reduction, or premature discontinuation of a previously authorized ongoing course of treatment.

•Failure of Longevity Health  to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee.

If Longevity Health denies an enrollee’s request for an item, service in whole or in part, or any amounts the enrollee must pay for a service (issues an adverse organization determination), the enrollee may appeal the decision to the plan by requesting a reconsideration.

A reconsideration consists of a review of an adverse organization determination or termination of services decision, the evidence, and findings upon which it was based, and any other evidence that the parties submit or that is obtained by the health plan, the QIO, or the independent review entity.

• An enrollee or an enrollee’s appointed or authorized representative may request a standard or expedited reconsideration.

• A non-contract physician or provider to a Medicare Health plan may request a standard reconsideration without being appointed as the enrollee’s representative, on the enrollee’s behalf.

• Non-contract providers must include a signed Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal.

• A physician regardless of whether the physician is affiliated with the plan may request that a Medicare Health Plan expedite a reconsideration.

Contract providers do not have appeal rights.

Reconsideration requests must be filed with the health plan within 60 calendar days from the date of the notice of the organization determination.

Expedited requests can be made either orally or in writing.

Standard requests must be made in writing unless the enrollee’s plan accepts oral requests. An enrollee should call the plan or check his or her Evidence of Coverage to determine if the plan accepts oral standard requests.

You or your representative can request a standard or expedited reconsideration by writing directly to us at:

Fax: 1-855-969-5853

Mail:
Longevity Health Plan
Appeals and Grievances Department
PO Box 21063
Eagan, MN 55121

Contact Member Services Department at our toll-free number at:

• Longevity Health Plan of Florida: 1-866-224-9499 (TTY 711)

• Longevity Health Plan of Illinois 1-888-886-9770 (TTY 711)

• Longevity Health Plan of New Jersey 1-888-899-8490 (TTY 711)

• Longevity Health Plan of New York 1-888-885-7337 (TTY 711)

• Longevity Health Plan of North Carolina 1-888-312-5196 (TTY 711)

• Longevity Health Plan of Michigan 1-888-312-8825 (TTY 711)

• Longevity Health Plan of Colorado 1-888-313-3609 (TTY 711)

You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you 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. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.

A party must file the request for reconsideration within sixty (60) calendar days from the date of the notice of the organization’s determination. If a request for reconsideration is filed beyond the sixty (60) calendar day time frame and good cause for late filing is not provided, Longevity Health will forward the request to the independent review entity for dismissal.

Once the plan receives the request, 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 30 calendar days for standard requests, or 60 calendar days for payment requests.

Our plan can accept or deny your request. If we approve your request for a standard reconsideration, our approval is valid until the end of the plan year.

A grievance is a type of complaint that does not involve payment or denial of services by Longevity Health. For example, you would file a grievance if:

• You have a problem with things such as the quality of your care during a hospital stay;

• You feel you are being encouraged to leave your plan;

• Waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room;

• Waiting too long for prescriptions to be filled;

• The way your doctors, network pharmacists or others behave;

• Not being able to reach someone by phone or obtain the information you need; or

• Lack of cleanliness or the condition of the office.

A grievance may be filed by any of the following:

• You may file a grievance

• Your authorized representative

If you wish to appoint someone to file an appeal on your behalf such as a family member, caregiver, or participating provider, you must complete an Appointment of Representation. More information on this requirement can be found here.

You are encouraged to use the grievance procedure when you have any type of complaint with Longevity Health, especially if such complaints result from misinformation, misunderstanding, or lack of information.

• Longevity Health Plan of Florida: 1-866-224-9499 (TTY 711)

• Longevity Health Plan of Illinois 1-888-886-9770 (TTY 711)

• Longevity Health Plan of New Jersey 1-888-899-8490 (TTY 711)

• Longevity Health Plan of New York 1-888-885-7337 (TTY 711)

• Longevity Health Plan of North Carolina 1-888-312-5196 (TTY 711)

• Longevity Health Plan of Michigan 1-888-312-8825 (TTY 711)

• Longevity Health Plan of Colorado 1-888-313-3609 (TTY 711)

•Longevity Health Plan of Massachusetts 1-855-969-5876 (TTY 711)

Fax: 1-855-969-5853

Mail:
Longevity Health Plan
Appeals and Grievances Department
PO Box 21063
Eagan, MN 55121

If you would like you can file a complaint directly to Medicare by filling out the complaint form at https://www.medicare.gov/MedicareComplaintForm/home.aspx.

• Longevity Health Plan of Florida: 1-866-224-9499 (TTY 711)

• Longevity Health Plan of Illinois 1-888-886-9770 (TTY 711)

• Longevity Health Plan of New Jersey 1-888-899-8490 (TTY 711)

• Longevity Health Plan of New York 1-888-885-7337 (TTY 711)

• Longevity Health Plan of North Carolina 1-888-312-5196 (TTY 711)

• Longevity Health Plan of Michigan 1-888-312-8825 (TTY 711)

• Longevity Health Plan of Colorado 1-888-313-3609 (TTY 711)

•Longevity Health Plan of Massachusetts 1-855-969-5876 (TTY 711)

A coverage determination is a decision made by our plan (not the pharmacy) about your prescription drug benefits, including:

• Whether a drug is covered

• Whether you have met all the requirements for getting a requested drug

• How much you’re required to pay for a drug, and

• Whether to make an exception to a plan rule when you request it

If a drug is not covered on our plan, you can ask the plan to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or another prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.

A coverage determination may be requested by any of the following:

• You or your representative may request a coverage determination.

• Your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) can request a coverage determination for you on your behalf.

• Covering a Part D drug for you that is not on our plan’s List of Covered Drugs (Formulary).
• You may ask our plan for an exception if you or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) believes you need a drug that isn’t on your drug plan’s list of covered drugs.
• You may ask for an exception if your network pharmacy can’t fill a prescription as written.
• Removing a restriction on the plan’s coverage for a covered drug.
• You may ask for an exception if you or your prescriber believe that a coverage rule (such as prior authorization) should be waived.
• Changing coverage of a drug to a lower cost-sharing tier. (Tier Exception)
• You may ask for an exception if you think you should pay less for a higher tier drug because you or your prescriber believe you can’t take any of the lower-tier drugs for the same condition.
• Request for payment.
• You may ask us to pay for a prescription that you already paid for.

Your doctor or other prescribers must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include medical information from your doctor or other prescribers when you ask for the exception.

Our plan can accept or deny your request.

If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true if your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. If your health requires a quick response, you must ask us to make a “fast decision”.