If you receive an unfavorable Part C coverage determination (denial), you have the right to file an appeal by following the instructions given on the determination or as outlined below.
Can I file an expedited appeal on an adverse initial determination?
An expedited appeal can be requested if you believe that waiting for a decision under the standard time frame could seriously jeopardize the life or health of the member, or the ability to regain maximum function.
Who can submit a Part C appeal?
As a CarePlus member, you, your representative, or your physician can submit a Part C appeal. If you would like to appoint a representative to handle this request for you, more information is available on our
How to file a Part C appeal
By phone
Call CarePlus
By fax or mail
Download a copy of the Grievance or Appeal Request Form in
Fax: 1-800-956-4288
Mailing address:
CarePlus Health Plans, Inc.
Attention: Grievance and Appeals department
P.O. Box 277810
Miramar, FL 33027
Please be sure to include all supporting documentation along with your appeal to facilitate a comprehensive review.
Decision timeframes
After we receive your appeal, we will send you our decision in writing by mail within the following timeframes:
Expedited appeal – 72 hours
Standard item or service appeal – 30 calendar days
Payment appeal – 60 calendar days
Waiver of Liability
If an out-of-network doctor files an appeal for a denied claim, he or she must include a completed a Waiver of Liability Form with the appeal request The Waiver of Liability states that the non-contracted (out-of-network) healthcare provider will not bill you, regardless of the outcome of the appeal.
If you receive an unfavorable drug coverage determination (denial), you have the right to appeal. Here is how the Part D appeal process works.
Who can submit a Part D appeal request?
As a CarePlus member, you, your representative, or your physician can submit a Part D appeal. If you would like to appoint a representative to handle this request for you, more information is available on our
How to file a Part D appeal
Online
Submit an online request in
By phone:
Call CarePlus Grievance and Appeals department. Calls to this number are free. We are open Monday – Friday, from 8 a.m. to 8 p.m. You may always leave a voicemail after hours, Saturdays, Sundays, and holidays and we will return your call within one business day.
1-800-451-4651 (TTY: 711).
By fax or mail
Download the Request for Redetermination of Medicare Prescription Drug Denial Forms in
Fax: 1-877-556-7005
Mailing address:
CarePlus Health Plans, Inc.
Attention: Grievance and Appeals department
P.O. Box 14165
Lexington, KY 40512-4165
Required Documentation
Please be sure to include the following information to facilitate a comprehensive review:
Your prescription drug name and Rx number.
The reason for your appeal.
Any clinical rationale given to you by your prescriber.
The prescriber’s name and phone number.
Decision timeframes
After we receive your appeal, we will send you our decision in writing within the following timeframes:
Expedited appeal– 72 hours
Standard appeal – 7 calendar days
Payment appeal – 14 calendar days
