See chapter 9 of your plan’s Evidence of Coverage (EOC). For data on the number of grievances and appeals for Medicare Advantage plans from Medica Advantage contact member services at 1-877-301-3326 (TTYT: 711).
Coverage decisions are the first decisions we make regarding your care, drugs, or payments.
A standard coverage decision for medical care means we will give you an answer within 14 calendar days after we receive your request. A fast coverage decision means we will answer within 72 hours.
A standard coverage decision for drugs means we must give you our answer within 72 hours after we receive your request. For a fast coverage decision about the drug(s) or payment you need, we must give you our answer within 24 hours.
See the latest National Coverage Determination updates.
To request a coverage decision for medical care, drugs, or payment, you, your appointed representative, or physician should contact us by telephone, fax, or mail using this contact information:
1-608-252-0840
1-855-673-6507
Medica Central Health Plan
PO Box 56099
Madison, WI 53705-9399
Medica Central Health Plan
PO Box 1039
Appleton, WI 54912-1039
You, your prescriber, or member representative may ask for a coverage decision via secure email outlined in the CMS drug coverage determination form.
Mail or fax us a copy of the itemized prescription receipt along with a copy of the register receipt, if available. Note: the register receipt alone is not adequate because it doesn’t have all pertinent information needed for reimbursement.
The itemized receipt should contain the following information:
Medica Central Health Plan
PO Box 1039
Appleton, WI 54912-1039
1-608-252-0812 for Medical complaints
1-855-673-6507 for Part D Prescription complaints
If you are requesting reimbursement, complete the patient's request for medical payment form. Mail the form along with your bill and documentation of any payment you've made. It is a good idea to make a copy of the bill and receipts for your records.
Medica Central Health Plan
PO Box 852159
Richardson, TX 75085-2159
Medica Central Health Plan
PO Box 1039
Appleton, WI 54912-1039
An appeal means we will review an unfavorable coverage determination.
A grievance is any complaint or dispute (dissatisfaction) other than one involving an organization determination. It is different from a coverage determination request; it usually will not involve coverage or payment for Part D drug benefits or Part C medical benefits.
In most cases, you only have 60 calendar days from an event to file a grievance or appeal. You may be eligible to file a grievance or appeal after 60 calendar days when you provide a good cause reason for missing the deadline. If we do not accept your good cause reason, we will notify you in writing.
To obtain an aggregate number of grievances, appeals, and exceptions filed with the Plan/Part D Sponsor, contact Customer Service at the number on your member ID card.
You can file an appeal if you want us to reconsider a decision we have made about your Part D prescription drug benefits or cost sharing associated with your Part D drug coverage.
You can file an appeal if you want us to reconsider a decision we have made about your Part C medical prior authorization or Part C medical claim or cost share associated with your Part C medical coverage.
A standard appeal decision means we have up to 30 days (pre-service) or 60 days (post service) from the time we receive your request to make a decision.
A fast appeal decision means we have up to 72 hours from the time we receive your request to make a decision.
You, your prescriber, or member representative may ask for a redetermination (appeal) using the Medicare redetermination request form.
To check status or to request a standard or fast grievance or an appeal, you, your appointed representative, or your prescribing physician should contact us by telephone, fax, mail, or hand-deliver at these numbers or addresses:
1-877-301-3326
Medica Central Health Plan
1277 Deming Way
Madison, WI 53717
Medica Central Health Plan
PO Box 1039
Appleton, WI 54912-1039
Medica Central Health Plan
Route CW595
PO Box 9310
Minneapolis, MN 55440-9310
1-855-673-6507 for Part D Prescription complaints
1-608-252-0812 for Medical complaints
You may request a review by Livanta, a Quality Improvement Organization (QIO), if your complaint relates to one of the following situations:
Livanta can be reached at 1-888-524-9900 or by mail at the following address:
Livanta BFCC-QIO
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701
You must act quickly when filing with Livanta as a request must be made before you leave the hospital and no later than your planned discharge date.
You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Others may already be authorized by the court or in accordance with state law to act for you. If you want someone to act for you who is not already authorized by the court or under state law, then you and that person must sign and date a statement that gives the person legal permission to be your representative.
If you prefer that someone else acts on your behalf, fill out the CMS appointment of representative form and mail it. Or if you have questions, call member services.
If you have complaints or concerns about our plans and would like to contact Medicare directly, use the CMS complaint form.
You, your appointed representative, or your prescribing physician can check the complaint status or submit a complaint by telephone, fax, mail, or hand deliver using this contact information:
1-877-301-3326
Part C Medical
Medica Central Health Plan
Route CW595
PO Box 9310
Minneapolis, MN 55440-9310
Part D Drug
Medica Central Health Plan
PO Box 56099
Madison, WI 53705-9399
1-608-252-0812 for Medical complaints
1-608-252-0889 for Part D Prescription complaints
Medica Central Health Plan
1277 Deming Way
Madison, WI 53717
The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests. See the Ombudsman website.
1-833-301-3326 (TTY:711)
1-888-HMO-9050
(1-888-466-9050)
1-800-Medicare
(1-800-633-4227)
Recorded and live help available 24 hours a day/seven days a week.
TTY: 1-877-486-2048
As a Medica Medicare Advantage member, you can:
You have the right to request a coverage determination from your Medicare drug plan if you disagree with information provided by the pharmacy. You also have the right to request a special type of coverage determination called an “exception” if you believe:
You or your prescriber can contact your Medicare drug plan to ask for a coverage determination by calling the plan’s toll-free phone number on the back of your plan membership card, or by going to your plan’s website.
You or your prescriber can request an expedited (24 hour) decision if your health could be seriously harmed by waiting up to 72 hours for a decision. Be ready to tell your Medicare drug plan:
See your plan materials or call 1-800-Medicare for more information. Recorded and live help available 24 hours a day, seven days a week.