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
2300 Park Drive, Suite 100
Owatonna MN , 55060
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
    
  • 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
    
  • 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:
  • 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
    
  • Address
    
  • City
    
  • State
    
  • Zip Code
    
  • Office Phone
    
  • Fax
    
  • 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 you 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.
• • Signature of person requesting the appeal (the enrollee, or the enrollee's prescriber or representative):
  • 
  • Date:

• H2419, H5703_4170_C