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.

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.

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

You can ask for a "fast" or "expedited" 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. Please note, "fast" decisions only apply for Part D drugs that you have not yet received. A "fast" coverage determination is made typically within 24 hours.

To check status or to request a "standard," "fast," or "expedited" coverage determination: you, your appointed representative or your prescribing physician may contact us by phone, fax, or mail using the information below:

Phone:

503-574-8000 or 1-800-603-2340 (TTY: 711), 8 a.m. to 8 p.m. (Pacific Time) 7 days a week, October 1st through March 31st and Monday - Friday, April 1st through September 30th.

Fax:

503-574-8646 or 1-800-249-7714

Mail to:

Providence Medicare Advantage Plans
Attn: Pharmacy Services
P.O. Box 3125
Portland, OR 97208-3125

You, your prescriber, or member representative may also request a coverage determination using one of the following methods:

• Option 1: Submit your application via secure online form.
• Option 2: Download, print, and fill out a PDF form. You can mail or fax the form to Providence Medicare Advantage Plans, Attn: Pharmacy Services.

Please mail or fax 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 sufficient, as it does not contain all of the necessary information required for processing a Direct Member Reimbursement (DMR) (PDF).

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 3125
Portland, OR 97208-3125

Fax:

503-574-8646 or 1-800-249-7714

Appeals

An appeal is the process used to request a review of an unfavorable coverage determination. You may file an appeal if you would like us to reconsider a decision we have made regarding your 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 applies only to Part D drugs you have not yet received. In these cases, a decision will be made within 72 hours of receiving your request.

Grievances

A grievance is any complaint or expression of dissatisfaction that does not involve a coverage determination. It is different from a coverage determination request as 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 from the date we receive your compliant.

If you disagree with our decision not to process your request as a “fast” decision, you may file an expedited grievance with us. We will respond to your expedited grievance within 24 hours.

To check status or to request a "standard," "fast" or "expedited" appeal, or a grievance: You, your appointed representative or your provider should contact us by phone, fax, mail, or hand deliver using the information below:

Phone:

503-574-8000 or 1-800-603-2340 (TTY: 711), 8 a.m. to 8 p.m. (Pacific Time) 7 days a week, October 1st through March 31st and Monday - Friday, April 1st through September 30th.

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
4400 N.E. Halsey St., Bldg. 2, Ste. 690
Portland, OR 97213

You, your prescriber or member representative may ask for a redetermination (appeal) by completing the following request form:

• Option 1: Submit your request via secure online form.
• Option 2: Download, print and fill out a PDF form. You can then mail or fax the form to Providence Medicare Advantage Plans.

You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act on your behalf. 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 someone else to act on your behalf, please complete one of the CMS appointment of representative forms (PDF)  listed below, sign it and return it to us using one of the methods list below:

Appointment of Representative (CMS 1696) - English
Appointment of Representative (CMS 1696) - English Large Print
Nombramiento de Representante (CMS 1696) - Spanish
Nombramiento de Representante (CMS 1696) - Spanish Letra Grande

• Mail to: Providence Medicare Advantage Plans, Attn: Appeals and Grievance Department P.O. Box 4158 Portland, OR 97208-4158.
• Fax to: 503-574-8757 or 1-800-396-4778.
• Call – if it is a fast appeal– 503-574-8000 or 1-800-603-2340, TTY: 711, 8 a.m. to 8 p.m. (Pacific Time) 7 days a week, October 1st through March 31st and Monday - Friday, April 1st through September 30th.

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

503-574-8000 or 1-800-603-2340, TTY: 711, 8 a.m. to 8 p.m. (Pacific Time) 7 days a week, October 1st through March 31st and Monday - Friday, April 1st through September 30th.

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
24 hours a day, 7 days a week