Fillable Part D QIC Drug Appeal Case File Transmittal (Medicare Part D Appeals)

Fill Online, Printable, Fillable, Blank Part D QIC Drug Appeal Case File Transmittal (Medicare Part D Appeals) Form

Use Fill to complete blank online MEDICARE PART D APPEALS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Part D QIC Drug Appeal Case File Transmittal (Medicare Part D Appeals)

On average this form takes 30 minutes to complete

The Part D QIC Drug Appeal Case File Transmittal (Medicare Part D Appeals) form is 3 pages long and contains:

  • 1 signature
  • 98 check-boxes
  • 72 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Medicare Part D Appeals forms online.

BROWSE MEDICARE PART D APPEALS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
d. Does this case involve a cost sharing issue?
e. Is this case an auto forward?
f. Is this a prior authorization appeal?
Part D Drug QIC Case File Transmittal Form
v7.5
Page 1 of 3
Part D QIC Drug Appeal Case File Transmittal Form
1. Appeal Information:
(Check one for each line.)
a. Priority:
Expedited Standard
b. Appea
l Type:
Prospective Retrospective
c. Applicable Coverage Year(s): _______________________
Yes No
Yes No
2. Enrollee Data:
Enrollee Name:
Enrollee (HICN) or Enrollee (MBI):
Enrollee Street:
_______________________
______________________
_______________________ Enrollee Phone:
Enrollee City: State: Zip:
Enrollee Date of Birth:
Is the Enrollee Deceased? Yes No
Does the Enrollee Require the final determination notice in a language other than English?
No
Yes Language needed:
____________________
_________________________ ___________ _______________
____________________
Does the Enrollee require communication be made in any alternate format?
No
Yes Specify format:
Large print (if other than 18 point font, indicate size below) Audio CD Braille Qualified Reader
Other (specify type of format or font)
__________
3. Requestor Data:
Enrollee is requestor Enrollee’s treating physician
Enrollee’s estate, Is estate documentation in file? Yes No
Representative, Is an AOR or Power of Attorney in file? Yes No
Surrogate acting in accordance with state law Yes No
Plan Attestation for Representative Appeals:
I attest on behalf of the Part D Plan sponsor that the above referenced representative appealed at the Plan level and is a
valid representative of the enrollee under State law.
Signed:_________________________________________ Print Name: _____________________________________
Requested appeal at Coverage Determination
Requested appeal at Redetermination
Name of Requestor: ___________________________ Company Name: _______________________
Phone: ____________________ Fax: ____________________ Email: ____________________
Street: ______________________________City: _________________________State: ______ Zip: __________
4. Medicare Health Plan Data:
Plan Type:
PDP (S#) MA PD (H or R#) MMP (H# or R#) Cost Employer Sponsored (E#)
Plan Contract #: ___ Enter 4-digit CMS Plan #: _________ Plan ID #: _____ Formulary Name/Formulary ID #: _______
Plan Contact Representative Name and Title:
Contact Phone: ___________________ Fax: _______________ Email: ___________________
Contact Address: ______________________ City: ___________________ State: ___________ Zip: _________
1. If yes, Has the plan chosen to waive or relax PA requirements due to COVID-19? Yes
to COVID-19, the plan must submit any prior
authorization flexibilities and the applicable timeframes the plan may have used in their coverage review.
No
2. If the plan has chosen to waive or relax PA requirement due
1. Is this auto-forward in relation to an at-risk determination?
Yes No
Yes No
click to sign
signature
click to edit
Coverage Determination (CD):
Plan Level 0: Coverage Determination:
For Determinations Involving an Exceptions Request:
Part D Drug QIC Case File Transmittal Form
v7.5
Page 2 of 3
Date Coverage Determination requested:
Did the Appellant ask the Plan to expedite? Yes No
Did the Plan grant an expedited review? Yes
No
Did the Plan extend the minimum timeframes to obtain a prescriber statement? Yes
No
Date prescriber statement requested:
Date prescriber statement received:
Decision Date:
Was CD untimely? Yes No
Plan Level 1: Redetermination:
Redetermination Decision (RD):
Drug Benefit in Dispute:
*** NOTE: If multiple drugs are in dispute, print and complete a separate version for each drug in dispute***
Condition (text only, no codes)
Retrospective Requests:
Date Redetermination requested:
Did the Appellant ask the plan to expedite? Yes No
Did the Plan grant an expedited review? Yes
No
Decision Date:
Was the RD untimely? Yes
No
Name of Drug:
Strength/Dosage/Amount/Refill Number (e.g. 20 mg BID for mos. No. 180, 1 refill):
Is prescriber requesting:
Brand Generic Either Acceptable (check one)
Off formulary? Yes
No
Has Enrollee purchased the drug pending appeal? Yes
No
If Yes: Date Purchased: Amount Paid:
Purchased from a network pharmacy? Yes
No
Date(s) of Purchase: Amount(s) Paid: Drug Tier:
Purchased from a network pharmacy? Yes
No
If No, explain:
Has this drug been approved as requested? Yes No
Drug Benefit Denial Rationale:
Utilization management rules not met Out-of-Network rules not met
Off-formulary exception rules not met Covered under A/B
Tiering exception rules not met Cost-sharing dispute
Excluded drug/use Not a Medically Accepted Indication
Drug is not FDA approved Other:
________________________________________________________________________
Prospective Requests:
Is this enrollee deemed 'At Risk'? Yes No
If yes, is the enrollee appealing a limitation, or the continuation of a limitation, on access to coverage for frequently
abused drugs (i.e., an enrollee specific point-of-sale (POS) edit, the selection of a prescriber and/or pharmacy for purposes of
lock-in); or information sharing for subsequent Part D plan enrollments. Yes No
Part D Drug QIC Case File Transmittal Form
v7.5
Page 3 of 3
Exhibits: Label applicable exhibits with letters provided below, and place them in order by letter.
Procedural Documents:
Evidentiary Documents:
A. Case Narrative cover page that presents an overview of the appeal: Describe the issue on appeal; identify all relevant
information; Identify all relevant information; Identify the arguments presented in favor of coverage; and Explain the Plan
rationale for denial.
B. Request for Coverage Determination and Plan Coverage Determination Decision Notice
C. Request for Coverage Redetermination and Plan Redetermination Decision Notice
D. Prescriber Statement (for exceptions requests)
E. Prior Authorization Form or Exception Request Form
F. Representation Documents (AOR or other writing, DPOA/POA, Healthcare Proxy, Surrogate for an incompetent enrollee
under State Law, estate representative
G. Other (describe or list below additional exhibits the Plan considers important)
H. Part D Plan Formulary (relevant exceptions and/or coverage criteria)
I. Part D Plan Evidence of Coverage or other Subscriber Materials (relevant portions)
J. Cost-Sharing Information (copies of internal Plan documents/screens showing TrOOP or other cost-sharing information as
relevant to the dispute)
K. Medical Records (separated by physician, labeled, and in chronological order with most recent on top)
L. Medicare Rules (Medicare law and regulations, CMS manuals, and/or CMS program guidance as relevant to the Part D
Plan’s determination)
M. Redetermination Evidence (evidence submitted by the appellant and/or the prescriber, and internal Plan medical reviews
conducted to evaluate medical necessity issues)
N. Other (describe or list additional exhibits the Plan considers important).
Prescriber Information:
Name of Physician/Prescriber:
Office Address:
Phone Number:
Fax Number:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Part D QIC Drug Appeal Case File Transmittal (Medicare Part D Appeals)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 31 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document