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Prospective & Enrolled Members: 1-800-405-9681 (TTY 711) | Provider Inquiries: 1-855-969-5907 (TTY 711)

Appeals, Organizational Determinations, Coverage Determinations, Grievances

To help us share our claims decision-making criteria with you as soon as we make updates, we have added a tool for you to access InterQual® criteria on our website. The Level of Care Criteria Application, also called the InterQual Transparency Tool, on the page is hosted by Change Healthcare.

We use Interqual Criteria for decisions involving:

  • medical and behavioral health inpatient levels of care and treatment
  • intermediate levels of care such as an intensive outpatient program or Long-term acute care
  • outpatient services such as homecare, procedures, outpatient rehabilitation, neuropsychological testing, and wound care treatment.
  • We also use InterQual criteria for select surgical procedures including but not limited to spine surgery, hysterectomies, and hip and knee replacement.

Transparency Tool

https://prod.ds.interqual.com/service/connect/transparency?tid=54960ff6-e199-4b42-81ec-cd0dfe0fa64e

How to access the Transparency Tool

  1. Once you click on the link above, you will be directed to Optum One Healthcare ID page.
  2. For first time users, you will need to register for an account; or you can log in with an existing account.
  3. You will be directed to then “Accept Interqual EULA- End User Licensing Agreement”. Click ACCEPT.
  4. You will be directed to access the criteria.
  5. Choose a subset under product.
    • LOC: Adult
    • LOC: Pediatric
    • LOC: Long Term Acute Care
    • LOC: Inpatient Rehab
    • LOC: Subacute/SNF
    • LOC: Home Care
    • LOC: Outpatient Rehabilitation & Chiropractic
    • BH: Adult and Geriatric Psychiatry
    • BH: Child and Adolescent Psychiatry
    • BH: Substance Use Disorders
    • BH: Behavioral Health Services
    • CP: Procedures
    • CP: Imaging
    • CP: Molecular Diagnostics
    • CP: Durable Medical Equipment
    • Medicare: Behavioral Health
    • Medicare: Imaging
    • Medicare: Molecular Diagnostics & Lab
    • Medicare: Pharmacy
    • Medicare: Post Acute & Durable Medical Equipment
    • Medicare: Procedures
  6. Choose a result and begin your medical review.

Your satisfaction and health are important to us. We’ll work with you to try to find a prompt resolution of your issue.

Please contact our Member Services number at 1-800-405-9681 for additional information. (TTY users should call 711). Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.

As a member of this plan and as someone who is getting Medicare, you have rights. We will treat you with respect and take your concerns seriously. If you would like to obtain a report of the appeals, grievance, and exceptions filed with the plan, you may contact Member Services and request that information.

Appeal and Grievance information is contained within Chapter 9 of the current year’s Evidence of Coverage document located under the Members menu. If you need personal assistance with any issue, please contact Member Services.

What is an Organization Determination/Coverage Determination?

An Organization Determination is a decision we make about whether items or services are covered or how much you have to pay for those covered items or services.

A Coverage Determination is a decision we make about what drugs are covered and how much you will have to pay for those drugs.

These types of decisions are sometimes called “Coverage Decisions”. Please refer to Chapter 9 in our Evidence of Coverage which provides detailed information on how you can file an Organization Determination for medical services and coverage determinations for prescription drugs.

How do I contact Provider Partners Health Plans when I’m asking for a coverage decision about my medical care?

  • CALL: Please contact our Member Services number at 1-800-405-9681 for additional information. (TTY users should call 711). Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.
  • WRITE: Provider Partners Health Plans
    PO Box 21063
    Eagan, MN 55121
  • FAX: 1-844-593-6221

How do I contact Provider Partners Health Plans/PBM (Pharmacy Benefit Manager) when I’m asking for a coverage decision about my prescription drugs?

  • CALL: Please contact our Member Services Department at our Pharmacy Benefit Manager at 1-844-846-8007 for additional information (TTY users should call 711). Our pharmacy Member Services is open 24 hours a day, seven (7) days a week.
  • WRITE:
    • Provider Partners Health Plans
      c/o MedImpact
      10181 Scripps Gateway Ct
      San Diego, CA 92131
  • FAX: 1-877-503-7231

Who may file an appeal?

You or your appointed representative may request an appeal. You may appoint someone to act on your behalf and serve as your representative for an appeal. You and your representative must sign the Appointment of Representative Form CMS 1696 (links below) and include this form with your appeal. The appointment is valid for one year unless revoked. A copy of this form must be included with any future appeals.

Your doctor can request an appeal for you. For medical care, your doctor can request a coverage decision or a Level 1 appeal on your behalf. For Part D prescription drugs, your doctor or the prescriber can request a coverage decision or a Level 1 or Level 2 appeal on your behalf.

Why file an appeal?

If you are not happy or if you disagree with a decision we make about what medical care or Part D drug is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appeal. For details on what to do if something is not covered for you in the way you think it should be covered, see Chapter 9 in our Evidence of Coverage. It provides the details on how to make an appeal if you want us to change our decision. Chapter 9 also explains how to make a complaint around quality of care, waiting times, and other concerns.

When do I file an appeal?

You have 60 calendar days from the date on our written notice to submit your appeal request. This notice informed you of our decision regarding your request for coverage. An example of good cause for missing the deadline may include but is not limited to a serious illness that prevented you from contacting us.

How do I file a medical appeal?

If your health requires it, your doctor can ask for a “fast appeal”. Your doctor must contact us at 1-855-969-5907 TTY 711 or in writing to: Provider Partners Health Plans, PO Box 21063, Eagan, MN 55121 or fax to 1-888-918-2989. Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.

If your health requires it, ask for a “fast appeal”, your doctor must contact us at 1-855-969-5907 TTY 711 or in writing to: Provider Partners Health Plans, PO Box 21063, Eagan, MN 55121 or fax to 1-888-918-2989. Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.

If you are asking for a “standard appeal”, make your standard appeal in writing by submitting a request to Provider Partners Health Plans, PO Box 21063, Eagan, MN 55121 or fax to 1-888-918-2989. Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.

How do I file a pharmacy appeal?

If you are asking for a “fast appeal” you can call Provider Partners Health Plans at 1-844-846-8007.

If you’re asking for a “standard appeal” make your standard appeal in writing only by filling out the Request for Redetermination of Medicare Prescription Drug Denial form (links below) and fax it to 877-503-7231 or mail it to:

MedImpact c/o Provider Partners Health Plans
ATTN: Part D Appeals
10181 Scripps Gateway Ct
San Diego, CA 92131

 

OR go to our Online Medicare Prescription Drug Coverage Determination/Appeal (Redetermination)

What if our plan denies your appeal?

If our answer is “no” to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal. Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. If you had a “fast appeal” at Level 1 you will also have a “fast appeal” at Level 2. If you had a “standard appeal” at Level 1, you will also have a “standard appeal” at Level 2.

Appeal Levels 3, 4, 5

If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. If the dollar value is high enough, the written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal.

What is a Grievance?

A grievance is a type of complaint you make about us or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

When do I file a grievance?

The complaint must be made within 60 days after you had the problem you would like to tell us about.

Where to send a compliant about Medical care?

Call our Member Services number at 1-800-405-9681 for additional information. (TTY users should call 711). Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and fax it to 888-918-2989 or mail it to:

Provider Partners Health Plans
PO Box 21063
Eagan, MN 55121

You can submit a complaint about Provider Partners Health Plans directly to Medicare. To submit an online complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx.

Where to send a complaint about Part D prescription drugs?

You may call Elixir’s Member Services at 1-844-846-8007. Calls to this number are free. Hours are 24 hours a day, 7 days a week. (TTY users should call 711)

You may mail in your complaint to:
MedImpact
c/o Provider Partners Health Plans
10181 Scripps Gateway Ct
San Diego, CA 92131

You can submit a complaint about Provider Partners Health Plans directly to Medicare. To submit an online complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx.

How to file an expedited or fast grievance

If you are making a complaint because we denied your request for a “fast appeal”, we will automatically give you a “fast complaint.” If you have a “fast complaint,” it means we give you an answer within 24 hours.

Call Member Services at 1-800-405-9681 (TTY 711) Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.

Appointing a Representative

You may appoint someone to act on your behalf and serve as your representative on an appeal. You and your representative must sign the Appointment of Representative Form CMS 1696 and include this form with your appeal. The appointment of your representative is valid for one year unless revoked. A copy of this form must be included with any future appeals.

If you become incapacitated or legally incompetent, a surrogate may be authorized by the court to act in accordance with State law to file an appeal on your behalf. In this case, an Appointment of Representative Form does not need to be executed. Instead, your surrogate must produce other appropriate legal papers supporting his or her status as your authorized representative when submitting an appeal on your behalf.

You Can Also Get Help From Medicare

For more information and help in handling a problem, you can also contact Medicare by doing one or more of the following:

How to Obtain the Aggregate Number of Grievances, Appeals and Exceptions Filed with Provider Partners Health Plans

If you are a provider, and need to obtain the aggregate number of Provider Partners Health Plans grievances, appeals and exceptions, please call Provider Services at 1-855-969-5907. for additional information. (TTY users should call 711).

Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.

Page Last Updated: 10/21/2024

Provider Partner Health Plans are HMO-SNPs with Medicare contracts. Enrollment in Provider Partner Health Plans depends on contract renewal. Y0135_PPHPWEB_2025_M