Initial Organizational Determinations, Appeals and Grievances
Click here to find information concerning initial organizational determinations, exceptions, appeals and grievances.
Also note that each Essence Healthcare plan’s Evidence of Coverage book describes our grievance, coverage determination (including exceptions) and appeals processes.
At any time during the grievance or appeal process, you may authorize a representative to assist you in the process. We must receive an authorization, in writing, from you to designate a representative. You can contact our customer service department for additional information about designating a representative. Click here for the form to appoint a representative to act on your behalf.
Click here to file a grievance or complaint on the Medicare.gov website.
You may print, complete and mail the form to the address located on the Essence Healthcare Contact Us page. The Medicare prescription drug coverage determination form should be mailed to the address located at the end of the form.
- Medicare Prescription Drug Coverage Determination Request Form
- Secure Online Form – Request for Medicare Prescription Drug Coverage Determination Form
- Paper-Based Form – Request for Medicare Prescription Drug Coverage Redetermination From
- Secure Online Form – Request for Medicare Prescription Drug Coverage Redetermination Form
- HIPAA Authorization Form
To obtain information about the aggregate number of grievances, appeals and exceptions filed with Essence Healthcare or for process or status questions, contact us.
Leaving or Switching Plans
“Disenrollment” from Essence Healthcare means ending your membership in our plan. Disenrollment can be voluntary or involuntary:
- You might leave Essence Healthcare because you have decided that you want to leave. You can do this for any reason; however, there are limits to when you may leave, how often you can make changes, what your other choices are for receiving Medicare services and how you can make changes.
- There are also a few situations where you would be required to leave our plan. For example, you would have to leave if you permanently move out of our geographic service area or if Essence Healthcare leaves the Medicare program. We will not ask you to leave our plan because of your health.
Until your membership ends, you must keep getting your Medicare services through Essence Healthcare, or you will have to pay for them yourself.
If you leave our plan, it may take some time for your membership to end and your new way of getting Medicare to take effect. While you are waiting for your membership to end, you are still a member and must continue to get your care as usual through our health plan.
If you get services from doctors or other medical providers who are not plan providers before your membership in our plan ends, neither Essence Healthcare nor the Medicare program will pay for these services, with just a few exceptions. The exceptions are: urgently needed care, care for a medical emergency, out-of-area renal dialysis services and care that has been approved by us. Another possible exception is if you happen to be hospitalized on the day your membership ends. If this happens to you, call us to find out if your hospital care will be covered. If you have any questions about leaving Essence Healthcare, please call us.
If you want to leave our health plan:
- The first step is to be sure that the type of change you want to make (and when you want to make it) fits within the rules explained below about changing how you get Medicare. If the change does not fit with these rules, you won’t be allowed to make the change.
- Then, what you must do to leave Essence Healthcare depends on whether you want to switch to Original Medicare or to one of your other choices.
In general, there are only certain times during the year when you can change the way you get Medicare. Your plan’s Evidence of Coverage outlines these rules. Contact us for information.
Potential for Contract Termination
If we leave the Medicare program or change our service area so that it no longer includes the area where you live, we will tell you in writing. If this happens, your membership in Essence Healthcare will end, and you will have to change to another way of getting your Medicare benefits. All of the benefits and rules described in the Evidence of Coverage will continue until your membership ends. This means that you must continue to get your medical care and prescription drugs in the usual way through our plan until your membership ends.
Your choices for how to get your Medicare coverage will always include Original Medicare and joining a prescription drug plan to complement your Original Medicare coverage. Your choices may also include joining another Essence Healthcare plan, another Medicare Advantage plan, or a private fee-for-service plan, if these plans are available in your area and are accepting new members. Once we have told you in writing that we are leaving the Medicare program or the area where you live, you will have a chance to change to another way of getting your Medicare benefits. If you decide to change from Essence Healthcare to Original Medicare, you will have the right to buy a Medigap policy regardless of your health. This is called a “guaranteed issue right.”
Essence Healthcare has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. At the end of each year, the contract is reviewed, and either Essence Healthcare or CMS can decide to end it. You will get 90 days advance notice in this situation. It is also possible for our contract to end at some other time during the year. In these situations, we will try to tell you 90 days in advance, but your advance notice may be as little as 30 or fewer days if CMS must end our contract in the middle of the year.
Whenever a Medicare health plan leaves the Medicare program or stops serving your area, you will be provided a special enrollment period to make choices about how you get Medicare coverage, including choosing a Medicare prescription drug plan and guaranteed issue rights to a Medigap policy.
Generally, we cannot ask you to leave the plan because of your health. If you ever feel that you are being encouraged or asked to leave our plan because of your health, you should call 1-800-MEDICARE (1-800-633-4227), which is the national Medicare help line. TTY users should call 1-877-486-2048. You can call 24 hours a day, seven days a week.
We can ask you to leave the plan under certain special conditions. If any of the following situations occur, we will end your Essence Healthcare membership:
- If you are not a United States citizen or lawfully present in the United States
- If you move out of the service area or are away from the service area for more than six months in a row. If you plan to move or take a long trip, please call us to find out if the place you’re moving to or traveling to is in our service area. If you move permanently out of our geographic service area, of if you’re away from our service area for more than six months in a row, you generally can’t remain a member of Essence Healthcare.In these situations, if you don’t leave on your own, we must end your membership (“disenroll” you)
- If you don’t stay continuously enrolled in both Medicare Part A and Medicare Part B
- If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our plan and you will lose prescription drug coverage
- If you give us information on your enrollment request that you know is false or deliberately misleading, and it affects whether or not you can enroll in our plan.
- If you lie about or withhold information about other insurance you have that provides prescription drug coverage
- If you behave in any way that is disruptive, to the extent that your continued enrollment seriously impairs our ability to arrange or provide medical care for you or for others who are members of a Essence Healthcare plan. We can’t make you leave our plan for this reason unless we get permission first from the Centers for Medicare & Medicaid Services, the government agency that runs Medicare
- If you let someone else use your plan membership card to get medical care. If you’re disenrolled for this reason, CMS may refer your case to the Inspector General for additional investigation
- If you become incarcerated (go to prison)
You have the right to make a complaint if we ask you to leave our plan. If we ask you to leave, we will tell you our reason(s) in writing and explain how you can file a complaint against us if you so choose.
Rights and Protections
As a Medicare beneficiary, you have certain rights to help protect you. You can read more about your rights and responsibilities as a member of Essence Healthcare in the Evidence of Coverage. You can also contact Medicare by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, seven days a week. You can also visit the Medicare website at www.medicare.gov. Following is a summary of our member’s rights and protections.
All Medicare Advantage plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue in the program, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
As an Essence Healthcare member, you have the right to request an initial organizational determination for medical services or a coverage determination for prescription drugs, which includes the right to request an exception. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at the pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s) or medical service, you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network providers that does not involve the coverage of services.
Using Out-of-Network Providers
With few exceptions, you must pay for services you receive from providers who are not part of the Essence Healthcare network unless Essence Healthcare has approved these services in advance. The exceptions are care for a medical emergency, urgently needed care, out-of-area renal (kidney) dialysis services, and services that are found upon appeal to be services that we should have paid or covered.
Quality Assurance & Utilization Management
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed the following requirements and limits for our plans to help us provide quality coverage to our members:
- Prior Authorization: We require you to get prior authorization for certain drugs. This means that your doctor will need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug. Click here to view our prior authorization criteria.
- Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Click here to view our step therapy criteria.
- Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time.
- Generic Substitution: When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug.
You can find out if the drug you take is subject to these additional requirements or limits by looking in the Drug Formulary. If your drug is subject to one of these additional restrictions or limits, and your physician determines that you are not able to meet the additional restriction or limit for medical necessity reasons, you or your physician can request an exception (which is a type of coverage determination).
Drug Utilization Review
We conduct drug utilization reviews for all of our members to make sure that they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:
- Possible medication errors
- Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
- Drugs that are not safe or appropriate because of your age or gender
- Possible harmful interactions between drugs you are taking at the same time
- Drug allergies
- Drug dosage errors
If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
Drug Transition Supply Policy
You may be able to get a temporary supply under certain circumstances. The plan can offer a temporary supply of a drug to you when your drug is not on the drug list or when it is restricted in some way. Doing this gives you time to talk with your doctor about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
- The change to your drug coverage must be one of the following types of changes:
- The drug you have been taking is no longer on the plan’s drug list.
- Or — the drug you have been taking is now restricted in some way (Chapter 5, Section 4 of the EOC talks about restrictions).
- You must be in one of the situations described below:
- For those members who are new or who were in the plan last year and are not in a long-term care (LTC ) facility:
- We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.
- For those members who are new or who were in the plan last year and reside in a long-term care (LTC) facility:
- We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are new and during the first 90 days of the calendar year if you were in the plan last year. The total supply will be for a maximum of a 31-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
- For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away:
- We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
- Members who have a change in level of care (setting) will be allowed up to a one-time 31-day transition supply per drug.
- For those members who are new or who were in the plan last year and are not in a long-term care (LTC ) facility:
Click here to view our Transition Policy.
Medication Therapy Management Program
Click here to view information about our Medication Therapy Management Program.
Find out if you qualify for extra Part D financial assistance by clicking here.
Please consult the Summary of Benefits and the Evidence of Coverage for other important enrollment and membership information. Medicare beneficiaries may also enroll in Essence Healthcare through the CMS Medicare Online Enrollment Center located at www.medicare.gov.