• Grievance, Appeals & Coverage Determinations

    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.
    You can file a grievance by phone, fax or mail. By clicking this link you can review and/or print the Grievance Form.

    Phone: 1-877-364-4566; TTY: 711
    Fax: 1-866-235-5181
    Mail: Clear Spring Health
    Attention: Appeals & Grievances
    PO Box 278530
    Miramar, FL 33027

    Note: Member Services is 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.)
    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.

    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 Appeal Form.

    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
    PO Box 278530
    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.)

    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.

    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.

    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.

    Online: Submit Coverage Review Determination Form
    Phone: 1-877-317-6082; TTY: 711
    Fax: 1-614-907-8547
    Mail: Clear Spring Health
    PO Box 278470
    Miramar, FL 33027

    Note: Coverage Determination/Exception phone hours are 8:00 a.m. – 8:00 p.m., 7 days a week.

    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.

    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.

    Click here to print or download the Authorization of Representative Form.

    Fax: 1-866-235-5181
    Mail: Clear Spring Health
    PO Box 278470
    Miramar, FL 33027

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

    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.

    Last Updated on April 28, 2021, 9:31 am CDT

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    Clear Spring Health, PO Box 278530 Miramar, FL 33027

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    Clear Spring Health has a contract with Medicare to offer PPO, HMO, and PDP Plans. Eon Health has a contract with the Georgia Medicaid program and a contract with the South Carolina Medicaid program. Enrollment in these plans depends on contract renewal.

    To learn more, please call MAPD: (877) 364-4566;   TTY users should call 711. Our office hours are October 1 – March 31, seven days a week, 8:00 a.m. – 8:00 p.m. and from April 1 – September 30, Monday through Friday, 8:00 a.m. – 8:00 p.m. (you may leave a voicemail Saturday, Sunday and Federal Holidays).

    Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.Llame al MAPD: 1-877-364-4566;   (TTY: 711)

    The portal is currently undergoing maintenance to improve user experience,
    we will be back up and running as soon as possible