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File an Appeal
What is an appeal?
An appeal is a formal request by the member (or his/her authorized representative) to change a decision previously made by Perennial Advantage.
For example, you may file an appeal for any of the following reasons:
- Perennial Advantage refuses to cover or pay for services you think Perennial Advantage should cover.
- Perennial Advantage or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
- Perennial Advantage or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
- If you think that Perennial Advantage is stopping your coverage too soon.
Who can file an appeal?
You or your authorized representative may file an appeal. You may also have your physician file an appeal on your behalf.
You may appoint an individual to act as your representative to file the grievance or an appeal for you by following the steps below.
Provide our health plan with:
- Your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: “I [your name] appoint [name of representative] to act as my representative in requesting an appeal from Perennial Advantage and/or CMS regarding the denial or discontinuation of medical services.”
- Your name, address and phone number and that of your representative, if applicable.
- A signed and dated statement by you and the person you are appointing as representative.
- You must include this signed statement with your appeal.
- Reasons for appealing, and any evidence you wish to attach.
- Supporting medical records, doctors’ letters, or other information that explains why your plan should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.
When can an appeal be filed?
You may file an appeal within sixty (60) calendar days of the date of the notice of the initial organization determination.
Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day time frame.
Where can an appeal be filed?
You may file a standard appeal in writing to:
Appeals and Grievances Department
PO Box 2190
Glen Allen, VA 23058
Call us to expedite an appeal:
1-844-788-6959 ( TTY 711) for Colorado or 1-844-788-6986 (TTY 711) for Ohio. Select option 6.
Can I expedite an appeal?
Yes, you may file an expedited appeal by calling: 1-844-788-6959 ( TTY 711) for Colorado or 1-844-788-6986 (TTY 711) for Ohio. Select option 6.
You have the right to request and receive expedited decisions affecting your medical treatment in “time-sensitive” situations. A “time-sensitive” situation is a situation where waiting for a decision to be made within the time frame of the standard decision-making process could seriously jeopardize 1) your life or health, or 2) your ability to regain maximum function.
If Perennial Advantage decides, based on medical criteria, that your situation is “time-sensitive” or if any physician calls or writes in support of your request for an expedited review, Perennial Advantage or your Primary Care Physician will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request.
What happens next
We will review your appeal. If any of the services you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by a reviewer outside of Perennial Advantage. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.