Medicare Plan (Ma, Mapd And Part D) Appeals & Grievances Form Page 3
Download a blank fillable Medicare Plan (Ma, Mapd And Part D) Appeals & Grievances Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medicare Plan (Ma, Mapd And Part D) Appeals & Grievances Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5Medicare Plan Appeals & Grievances form 3 of 5
What results do you want? (Example: have the plan pay for medical care or a drug.) Please tell us below.
Sign here
Date
When I sign above, I am stating the information on this form is correct, to the best of my knowledge.
I understand if I put information on this form I know isn’t true, I could face fines and prison under
federal law. If I sign as an authorized representative, it means I have the legal right under state law
to sign. I can show written proof of this right if Medicare asks for it.
Checklist
Please make sure you:
Sign above.
Keep copies of everything you send us.
If you are completing this for a member, please include a copy of the paperwork showing you
have the legal right to do so. Examples: Power of Attorney and Appointment of Representative
(AOR) form. You can find the AOR form here:
Forms/CMS-Forms-Items/CMS012207.html
Where to send this form
Medical Services Appeals and Grievances:
Prescription Drug Appeals and Grievances:
Mail: UnitedHealthcare
Mail: UnitedHealthcare
Appeals and Grievances Department
Appeals and Grievances Department
P.O. Box 6106, MS CA124-0157
P.O. Box 6106, MS CA124-0197
Cypress, CA 90630
Cypress, CA 90630
Fax: 1-888-517-7113
Fax: 1-866-308-6294
Definitions and helpful information
Appeal
An action you can take if you disagree with a coverage or payment decision the plan made.
For example, you can appeal if Medicare or your plan denies your request for:
• A health care service, supply, item, or prescription drug you think you should be able to get.
• Payment of a health care service, supply, item, or prescription drug you’ve already received.
• A change to the amount you must pay for a health care service, supply, item, or prescription drug.
Our deadline for a prescription drug appeal
The standard timeframe is 7 calendar days.
IR_170327_114708
MRAMR2810AG
SPRJ35121
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical