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Appeals (Parts C & D)

What is an appeal?

An appeal is a formal way of asking us to reconsider a decision that we have made about benefit coverage for you. If we make a decision that you are not satisfied with, you can ‘appeal’ it. You can appeal decisions about your medical care (reconsideration) or prescription drugs (redetermination). You need to appeal within 60 days of the decision. If you have a good reason for being late in appealing, let us know and we will consider whether or not to extend the timeline for appeals. If your health requires it, ask us to give you a “fast appeal”. A fast appeal is called an “expedited reconsideration” (Part C) or an “expedited redetermination” (Part D). To get a fast coverage decision, you must be asking for coverage for medical care or a drug you have not yet received. You can also get a fast coverage decision if it is determined that using the standard deadlines could cause serious harm to your health or hurt your ability to function.

Member Appeal Form (PDF)

Mail to:
Allwell from Magnolia Health
Attn: Appeals and Grievances/Medicare Operations
7700 Forsyth Blvd
Saint Louis, MO 63105

As a courtesy, you can utilize the plan form to file an appeal. Please note that you must submit a standard appeal in writing and you have the option of submitting an expedited appeal in writing. The timeframe for a decision on your appeal will start when we receive your request at the plan.

 


For process or status questions, you or your provider can contact Member Services.


What do we do when you file an appeal?

We will have a different doctor review your case to decide whether or not we should change our decision. We may ask for additional information from you or your doctor if needed. There are also specific timelines we must follow depending on what you ask for and how soon you may need that decision. We will process your appeal as fast as your health status and circumstances require, but no later than:

  • Medical Decisions (Part C) – Standard Process 30 days; Expedited Process 72 hours
  • Payment Decisions (Part C) – 60 days
  • Prescription Drug (Part D) – Standard Process 7 days
  • Prescription Drug (Part D) – Expedited Process 72 hours
  • Payment Decisions (Part D) – 14 days

How do non-contracted providers file a claim appeal?  

In accordance with the requirements established by the Centers for Medicare and Medicaid Services (CMS), non-contracted providers have Medicare appeal rights. Medicare appeal rights apply to any claim for which we have denied payment.

  • All requests for payment appeals must include a completed and signed Waiver of Liability (WOL) statement.

Non-Contracted Provider appeal requests should be submitted with the completed WOL, to the following address:

Allwell from Arkansas Health & Wellness
Grievance and Appeals – Medicare Operations
P.O. Box 3060
Farmington, MO 63640-3822