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As much as we try to meet your needs, we understand there may be times when you’re dissatisfied with some aspect of your medical or prescription drug coverage, our service or you need to make a special request. We want to be the first step in addressing your concerns.

There are three processes available to you:
Grievance, Appeal and Coverage Determination.

Grievance

A formal complaint that expresses dissatisfaction with any aspect of Clear Spring Health’s operations, activities or behaviors of its providers/partners. A grievance is not submitted to dispute a denied claim or service.

Appeal

A request for Clear Spring Health to reconsider a coverage related decision that we made about your medical or prescription drug benefit coverage. Some examples of an appeal include:

  • How a claim was paid, partially denied or denied
  • Denial of a request or authorization for a medical service, medical equipment or prescription

An expedited appeal, further described below, is a type of appeal used when the member’s health may be in immediate jeopardy.

Coverage Determination

This is the original decision Clear Spring Health (not the pharmacy) makes about your prescription drug benefits. This can be a decision about if your drug is covered, if you met the Clear Spring Health’s requirements to cover the drug or how much you pay for the drug.

An exception is a type of coverage determination and has multiple forms. Some examples are:

  • Formulary Exception – an exception that allows you to receive a drug that’s not on your selected Clear Spring Health plan’s formulary
  • Tier Exception – an exception that allows you to receive a non-preferred drug at the lower, preferred tier, cost-sharing level

Below is information about each process, including how and where to submit these requests. More detailed information on each of these processes is available in your Evidence of Coverage or by calling Member Services at the number on the back of your Clear Spring Health I.D. card.

Grievance

A grievance is a complaint about any aspect of your plan—for example, a problem with the service you receive, or you believe our communication or printed documents are difficult to understand. You or your authorized representative can file an oral or written grievance with our plan within 60 calendar days of the event.

Once Clear Spring Health receives your grievance, it will be investigated and you will be informed of our decision.

Please refer to the Evidence of Coverage under Member Plan Documents for more detailed information on specific timeframes and other elements of the grievance process, or call our Member Service team using the phone number on the back of your member I.D. card.


MAPD Contacts

Phone
1 (877) 364-4566; TTY: 711

Fax
1 (866) 235-5181

Mail
Clear Spring Health
Attention: Appeals & Grievances
3601 SW 160th Avenue, Suite 450
Miramar, FL 33027

Note: Member Services are available 8:00 a.m. – 8:00 p.m. (between April 1 – September 30, 2021; voicemail will be used on Saturday, Sunday and federal holidays)

MAPD Authorized Representative Form

MAPD Grievance Form

PDP – Prescription Drug Plan Contacts

Phone
1 (877) 842-9790; TTY: 1 (800) 899-2114

Fax
1 (614) 907-8547

Mail
Express Scripts
Attn: Grievance Resolution Team
P.O. Box 3610
Dublin, OH 43016-0307

Note: Member Services is available 24 hours a day, 7 days a week

PDP Authorized Representative Form

PDP Grievance Form

Appeal

An appeal is a request for us to reconsider an initial coverage decision that Clear Spring Health has made regarding your medical or prescription drug coverage or payment denial. Examples of reasons for an appeal include:

  • How a claim was paid, partially denied or denied
  • Denial of a request or authorization for a medical service, medical equipment or prescription drug

Expedited Appeal

If you believe waiting for the appeal decision under the standard timeframe may seriously jeopardize your health and/or ability to regain maximum function, you may request an expedited review, or Expedited Appeal.

You, your doctor, your pharmacist (only if related to a prescription drug) or your authorized representative can file an appeal (standard or expedited) by phone, fax or mail. By clicking this link you can review the Appeal Form.

Once Clear Spring Health receives your appeal, it will be investigated and you will be informed of our decision. There are various levels and specific timeframes associated with the appeals and expedited appeals processes. Please refer to the Evidence of Coverage under Member Plan Documents for more detailed information on the timeframes and other elements of the appeals process. Or, call Member Services using the phone number on the back of your member I.D. card.


MAPD Contacts

For medical (or Part C) appeals (standard and expedited):

Phone
1 (877) 364-4566; TTY: 711

Fax
1 (866) 235-5181

Mail
Clear Spring Health
Attention: Appeals & Grievances
3601 SW 160th Avenue, Suite 450
Miramar, FL 33027

Note: Medical/Part C appeals phone hours are 8:00 a.m. – 8:00 p.m. (between April 1 – September 30, 2021; voicemail will be used on Saturday, Sunday and federal holidays)

Waiver of Liability


For prescription drug (or Part D) appeals (standard and expedited):

Phone
1 (877) 842-9791;
TTY: (800) 899-2114

Fax
1 (614) 907-8547

Mail
Express Scripts
Attention: Appeals & Grievance
Resolution Team
P.O. Box 3610
Dublin, OH 43016-0307

Note: Prescription Drug/Part D appeals phone hours are 8:00 a.m. – 8:00 p.m., 7 days a week

PDP – Prescription Drug Plan Contacts

Phone
1 (844) 374-7377; TTY: 1 (800) 716-3231

Fax
1 (877) 852-4070

Mail
Express Scripts
Attn: Medicare Appeals
P.O. Box 66588
St. Louis, MO 63166-6588

Note: Phone hours are 24 hours a day, 7 days a week.

Coverage Determination

Coverage determinations and exceptions are specific to prescription drug coverage (regardless if it’s a stand-alone Medicare Part D plan or part of a Medicare Advantage Prescription Drug [MAPD] plan) and are used to ask for an advance approval to cover a prescription drug outside of the Clear Spring Health formulary rules.

You, your doctor or your authorized representative can request a coverage determination through our secure online portal, phone, fax or mail. By clicking this link, you can review and/or print the Coverage Determination Form.

You may also submit your request online by using this secure portal.

Please refer to the Evidence of Coverage under Member Plan Documents for more detailed information on the timeframes and other elements associated with the coverage determination process, or call Member Services using the phone number on the back of your member I.D. card.


Phone
1 (844) 374-7377;
TTY: 1 (800) 716-3231

Fax
1 (877) 251-5896

Mail
Express Scripts
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571

Online
Submit Coverage Determination Review Form
Submit Coverage Redetermination Review Form

Note: Coverage Determination/Exception phone hours are 24 hours a day, 7 days a week

Authorized Representative

You may choose to select an authorized representative to assist or handle affairs related to your health care services. This may be someone you designate as a Power of Attorney, a family member, friend, caregiver or an advocate you assign and is required to be on file with Clear Spring Health prior to the submission of a grievance, appeal or coverage determination.

To assign an authorized representative, complete the Appointment of Representative form, which must be signed by you and by the person you would like to act on your behalf, and submit to Clear Spring Health by fax or mail.

You may also use Medicare’s website to obtain the Appointment of Representative Form at https://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf.


MAPD Contacts

MAPD Authorized Representative Form

Fax
1 (866) 235-5181

Mail
Clear Spring Health
PO Box 278470
Miramar, FL 33027

PDP Prescription Drug Plan Contacts

PDP Authorized Representative Form

Phone
1 (877) 842-9790; TTY: 1 (800) 899-2114

Fax
1 (614) 907-8547

Mail
Express Scripts
Attn: Grievance Resolution Team
P.O. Box 3610
Dublin, OH 43016-0307

Note: Member Services is available 24 hours a day, 7 days a week

Additional Information

If you, your authorized representative or your provider have questions about these processes or want to obtain the aggregate number of grievance, appeal or coverage determination requests filed with Clear Spring Health, call Member Services using the phone number on the back of your member I.D. card.

You can also contact the Center for Medicare and Medicaid Services (CMS) at 1-800-Medicare for additional details about the grievance and appeals process. In lieu of calling, you can enter a complaint at Medicare.gov.

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Request a PDF Directory

Our MAPD Provider Directory includes thousands of primary care physicians (PCPs) and specialists across our service area of select counties in Colorado, Georgia, Illinois, South Carolina, and Virginia.

Due to the directory size we recommend using the Provider Search above to more accurately locate the providers in your area. However, if you still prefer a printed copy, please contact Member Services at 1 (877) 364-4566.