Medicare Part D coverage determinations, exceptions, appeals and grievances

If you have a concern or are having a problem as a Providence Medicare Advantage Plans member, there are three types of processes (coverage determinations, appeals and grievances) to follow depending on the nature of the issue. The information below will help you determine the best way to proceed.

How do I find out more information about my plan's grievance, determination and appeals process?

If you have prescription drug coverage please refer to chapter 9 of your plan's evidence of coverage (EOC) for more information regarding grievance, determination and appeals processes.

What are coverage determinations?

Coverage determinations are the first decisions made by the plan that determine whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exception requests.

"Standard" coverage determination: For a "standard" coverage determination, the decision will typically be made within a 72-hour timeframe. 

"Fast" or "expedited" coverage determination: You can ask for a "fast" coverage determination ONLY if you or your doctor determine that waiting for a standard decision could seriously harm your health or your ability to function. "Fast" decisions only apply for Part D drugs that you have not yet received. A "fast" coverage determination is made typically within 24 hours.

How do I request a coverage determination exception?

To check status or to request a "standard," "fast" or "expedited" coverage determination: you, your appointed representative or your prescribing physician should contact us by telephone, fax or mail at the numbers or address below: 

Phone: 503-574-7400 or 1-877-216-3644, M-Sun, 8 a.m. to 8 p.m.
Fax: 503-574-8646 or 1-800-249-7714 

Mail to:
Providence Medicare Advantage Plans
P.O. Box 4327
Portland, OR 97208-4327 

You, your prescriber or member representative may ask for a coverage decision via secure email by using one of the drug coverage determination forms below: 

How do I submit a paper claim?

Please mail or fax in a copy of the itemized prescription receipt along with a copy of the register receipt if available. Please note the register receipt alone is not adequate as it doesn't have all pertinent information needed for a Direct Member Reimbursement (DMR).

The itemized receipt should contain the following information:

  • Pharmacy Name, Address, Phone Number
  • Prescription (Rx) Number
  • Date of Service
  • Drug Name
  • National Drug Code (NDC)
  • Quantity and Day Supply
  • Provider Name
  • Member Cost/Responsibility

Mail to:
Providence Medicare Advantage Plans
Attn: Pharmacy Services
P.O. Box 4327
Portland, OR 97208-4327

Fax: 503-574-8646 or 1-800-249-7714

What is an appeal? What is a grievance?

Appeals

An appeal is the process that deals with the review of an unfavorable coverage determination. You can file an appeal if you want us to reconsider a decision we have made regarding you Part D prescription drug benefits or cost sharing associated with your Part D drug coverage.

A "standard" appeal decision means we have up to 7 calendar days from the time we receive your request to make a decision on a "standard" appeal.

A "fast" appeal decision means an appeal decision for a Part D drug you have not received may take up to 72 hours from the time we receive your request.

Grievances

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.

Grievance decisions will be made as quickly as your case requires but no later than 30 calendar days after receiving your complaint.

If you request a "fast" grievance regarding a denial to expedite your appeal, a decision will be rendered within 24 hours.

How do I request an appeal or grievance?

To check status or to request a "standard," "fast" or "expedited" appeal or a grievance: You, your appointed representative or your prescribing physician should contact us by telephone, fax, mail or hand deliver at the numbers or address below:

Phone:503-574-8000 or 1-800-603-2340 (TTY: 711), M-Sun, 8 a.m. to 8 p.m.
Fax: 503-574-8757 or 1-800-396-4778

Mail to: 
Providence Medicare Advantage Plans
Attn: Appeals and Grievance Department
P.O. Box 4158
Portland, OR 97208-4158

Hand deliver to: 
Providence Medicare Advantage Plans
3601 SW Murray Blvd., Suite 10
Beaverton, OR 97005

You, your prescriber or member representative may ask for a redetermination (appeal) via secure email by completing the Providence Medicare Advantage Plans redetermination form.

Appointing a representative

You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons 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. To learn how to name your representative, you may call customer service.

If you would prefer that someone else act on your behalf, please complete the CMS' appointment of representative form (PDF), sign it and return it to us one of the following ways:

  • Mail to: Providence Medicare Advantage Plans, Attn: Appeals and Grievance Department P.O. Box 4158 Portland, OR 97208-4158.
  • Fax to: 1-800-396-4778.
  • Call – if it is a fast appeal – 503-574-8000 or 1-800-603-2340, TTY: 711, M-Sun, 8 a.m. to 8 p.m.
  • Visit us at: Providence Medicare Advantage Plans, Attn: Appeals and Grievance Department 3601 SW Murray Blvd., Suite 10 Beaverton, OR 97005.

Medicare complaint form

If you have complaints or concerns about Providence Medicare Advantage Plans and would like to contact Medicare directly please complete the CMS' complaint form.

The Medicare Beneficiary Ombudsman

The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests.

Contact information

1-800-603-2340 or 503-574-8000, TTY: 711, M-Sun, 8 a.m. to 8 p.m.

Other resources

Medicare Rights Center
Toll-free: 1-888-HMO-9050
(1-888-466-9050)

Elder Care Locater
Toll-free: 1-800-677-1116

1-800-Medicare
(1-800-633-4227)
TTY: 1-877-486-2048