Request for Redetermination of Medicare Prescription Drug Denial

Because we South Country Health Alliance denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. This form may be sent to us by mail or fax:
Address:
South Country Health Alliance
6380 West Frontage Road
Medford MN , 55049
Attn: Pharmacy Prior Authorization/Member Prescription Coverage Determination
Fax Number:
Standard: (855)446-7904
Urgent: (855)446-7902
• You may also ask us for an appeal through our website at www.mnscha.org. Expedited appeal requests can be made by phone at (866)567-7242.
• Who May Make a Request: Your prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Contact us to learn how to name a representative.
• Enrollee's Information

  • Enrollee's Name
  • Date of Birth
    
  • Enrollee's Address
    
  • Enrollee's Address 2
    
  • Gender
    --Select-- Male Female
  • City
    
  • State
    
  • Zip Code
    
  • Phone
    
  • Enrollee's Member ID #
    
  • Complete the following section ONLY if the person making this request is not the enrollee or prescriber:
  • Requestor's Name
    
  • Requestor's Relationship To Enrollee
    
  • Address
    
  • Address 2
    
  • City
    
  • State
    
  • Zip Code
    
  • Phone
    
  • Representation documentation for appeal requests made by someone other than enrollee or the enrollee’s prescriber:
  • Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted at the coverage determination level. For more information on appointing a representative, contact your plan or 1-800-Medicare.
• • Name of prescription drug you are requesting:
  • Name of drug:
    
  • Strength/Quantity/dose:
  • Drug Allergies
  • Diagnosis
  • Have you purchased the drug pending appeal?
  • If "Yes" Date purchased:
  • Amount paid: $ (attach copy of receipt)
  • Name and telephone of pharmacy:

• Prescriber's Information

  • Name
    
  • Practice Name
    
  • NPI
    
  • Specialty
    -- Select -- Adolescent Medicine Alcohol & Substance Abuse Allergy Allergy & Immunology Ancillary Pre-Natal Care Anesthesiology Audiology Blood Products Supplier Cardiology Cardiothoracic Surgery Cardiovascular Case Management Cert Reg Nurse Anes CRNA Cert Reg Nurse Pract OBGY Cert Reg Nurse Practitioner Chiropractor Chiropractor Clinical Pharmacology Critical Care Dermatology Dermopathology Developmental Rehab Diabetes Educator Diabetology Dialysis Center Ears/Nose/Throat Emergency Room Physician Endocrinology Endodontists EPSDT MH Wraparound Family Practice FP, Maternal & Child Health Gastroenterology General Dentistry General Practice General Surgery Genetics Genetics and Infertility Geriatrics Gynecologic Oncology Gynecology Hematology Hematology & Oncology Hematology/Oncology HIV/AIDS Case Mgt Svcs Home Infusion Hospital Pathology Host HMO Immunology Infectious Disease Internal Medicine IV Therapy-Infusion Therapy Lithotripsy/Kidney Maternal Fetal Medicine Med Resonance Imaging Center Mental Retardation Metabolism Midwife Multiple Specialty Group Neonatology Nephrology Neuro-Ophthalmology Neurological Surgery Neurology Neuropathology Neurophysiology No Specific Medical Specialty Nuclear Medicine Nurse Practitioner Nutritionist OB/Gynecology Obstetrics Obstetrics Occularist Occulo Plast Reconst Surg Occupational Medicine Occupational Therapist Oncology Ophthalmic Pathology Ophthalmology Ophthalmology - Cornea Ophthalmology - Glaucoma Ophthalmology - Retina Ophthalomology-Plastic Recon Optical Supply Optician Optometry Oral and Maxillofacial Surgeon Oral Pathology Oral Surgery Orthodontics Orthodontists Orthopaedics Orthotics & Prosthetics Osteopathy Otorhinolaryngology Pain Management Pathology Pathology, Clinical Pediatric Anesthesiology Pediatric Critical Care Pediatric Dentistry Pediatric Genetics Pediatric Surgery Pediatrics Pediatrics Otorhinolaryngology Pediatrics, Allergy Pediatrics, Cardiology Pediatrics, Dermatology Pediatrics, Developmental Pediatrics, Emergency Medicine Pediatrics, Endocrinology Pediatrics, Gastroenterology Pediatrics, Hem/Onc Pediatrics, Hematology Pediatrics, Immunology Pediatrics, Infectious Disease Pediatrics, Internal Medicine Pediatrics, Metabolism Pediatrics, Nephrology Pediatrics, Neurology Pediatrics, Neurosurgery Pediatrics, Nurse Practitioner Pediatrics, Oncology Pediatrics, Ophthalmology Pediatrics, Orthopedic Surgery Pediatrics, Pathology Pediatrics, Pulmonology Pediatrics, Radiology Pediatrics, Rheumatology Pediatrics, Urology Pedodontics Periodontics Personal Care Pharmacist Physical Medicine & Rehab Physical Therapy Physician Assistant Plastic Surgery Podiatry Preventative Medicine Preventative Medicine Primary Care Vision Private Duty Nursing Private Mental Health Prosthetics & Orthotics Prosthodontics Psych Rehab-Subst Abuse Psychiatry Psychiatry, Child Psychiatry, Neurology Psychologist Pulmonary Disease Radiation Oncology Radiology Radiology, Diagnostic Radiology, Interventional Neur Radiology, Neuro Radiology, Therapeutic Reproductive Endocrinology Reproductive Genetics Rheumatology SED Children Sleep Disorders Social Worker Speech Pathology Speech Therapy Surgery, Cardiovascular Surgery, Colon and Rectal Surgery, Hand Surgery, Oncology Surgery, Orthopedic Surgery, Pathology Surgery, Pediatric Surgery, Plast. Maxillofacial Surgery, Plastic, Facial Surgery, Thoracic Surgery, Transplant Surgery, Urological Therapist-Multi Spec Group Urgent Care Urogynecology Urology Vascular Medicine Vascular Surgery Vitreoretinal Surg Xray
  • Address
    
  • Address 2
    
  • City
    
  • State
    
  • Zip Code
    
  • Office Phone
    
  • Fax
    
  • Contact Person
    
  • Prescriber's Signature:
    
  • Date:
• Attachments:
• • Attachments are optional. If needed you can upload and attach files to this request.
    The following file extensions are allowed: ".pdf, .doc, .docx, .xls, .xlsx, .ppt, .txt"
    Files must be 3 MB (3,000,000 bytes) or less.

  • ---

  • Attachment Type:
    Authorization of Representation Form (CMS-1696) Formulary Exception Documentation Tiering Exception Documentation Exception request Supporting Information Prior Authorization Supporting Information Expedited Request Supporting Information Chart Notes Lab Results Sample Logs Purchase Receipt Other
  • Select a file to upload:
     
• • Important Note: Expedited Decisions
  • If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.
  • CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS If you have a supporting statement from your prescriber, attach it to this request.
  • Please explain your reasons for appealing: Attach additional pages, if necessary. Attach any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records. You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage and have your prescriber address the Plan's coverage criteria, if available, as stated in the Plan's denial letter or in other Plan documents. Input from your prescriber will be needed to explain why you cannot meet the Plan's coverage criteria and/or why the drugs required by the Plan are not medically appropriate for you.
• • Signature of person requesting the appeal (the enrollee or the representative):
  • 
  • Date:

• H2419, H5703_4936_C