Coverage decisions are the first decision made by the plan on the medical care you are requesting or the drugs(s) or payment you need.
A standard coverage decision for medical care means we will give you an answer within 14 calendar days after we receive your request. A fast coverage decision means we will answer within 72 hours.
A standard coverage decision for drugs means we must give you our answer within 72 hours after we receive your request. For a fast coverage decision about the drug(s) or payment you need, we must give you our answer within 24 hours.
See the latest National Coverage Determination updates.
If you receive Extra Help from Medicare to pay your Medicare prescription drug plan costs, your monthly Dean Advantage premium will be reduced.
To request a coverage decision for medical care, drugs or payment, you, your appointed representative or physician should contact us by telephone, fax or mail at these numbers or addresses:
You, your prescriber or member representative may ask for a coverage decision via secure email outlined
in the CMS drug coverage determination form.
Mail or fax us a copy of the itemized prescription receipt along with a copy of the register receipt if available. Note: the register receipt alone is not adequate because it doesn’t have all pertinent information needed for reimbursement.
The itemized receipt should contain the following information:
Dean Advantage Plans
Attn: Part D Member Claims Department
P.O. Box 1039
Appleton, WI 54912-1039
Fax: 1-855-673-6507 or local 1-920-221-4650
If you are requesting reimbursement, complete the patient's request for medical payment form. Mail the form along with your bill and documentation of any payment you've made. It is a good idea to make a copy of the bill and receipts for your records.
Dean Health Plan
Attn: MAPD claims
1277 Deming Way
Madison, WI 53717
An appeal means we will review an unfavorable coverage determination.
A grievance is any complaint or dispute (dissatisfaction) other than one involving an organization determination. It is different from a coverage determination request; it usually will not involve coverage or payment for Part D drug benefits or Part C medical benefits.
In most cases, you only have 60 calendar days from an event to file a grievance or appeal. You may be eligible to file a grievance or appeal after 60 calendar days when you provide a good cause reason for missing the deadline. If we do not accept your good cause reason, we will notify you in writing.
You can file an appeal if you want us to reconsider a decision we have made about your Part D prescription drug benefits or cost sharing associated with your Part D drug coverage.
You can file an appeal if you want us to reconsider a decision we have made about your Part C medical prior authorization or Part C medical claim or cost share associated with your Part C medical coverage.
You, your prescriber or member representative may ask for a redetermination (appeal) using the Medicare redetermination request form.
To check status or to request a standard or fast grievance or an appeal, you, your appointed representative, or your prescribing physician should contact us by telephone, fax, mail or hand-deliver at these numbers or addresses:
You may request a review by Livanta, a Quality Improvement Organization (QIO), if your complaint relates to one of the following situations:
Livanta can be reached at 1-888-524-9900 or by mail at the following address:
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701
You must act quickly when filing with Livanta as a request must be made before you leave the hospital and no later than your planned discharge date.
You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Others may already be authorized by the court or in accordance with state law to act for you. If you want someone to act for you who is not already authorized by the court or under state law, then you and that person must sign and date a statement that gives the person legal permission to be your representative.
If you have complaints or concerns about Dean Advantage Plans and would like to contact Medicare directly, use the CMS complaint form.
You, your appointed representative or your prescribing physician can check the complaint status or submit a complaint by telephone, fax, mail or hand deliver at these numbers or addresses:
The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests. See the Ombudsman website.
As a Dean Advantage member, you can:
You have the right to request a coverage determination from your Medicare drug plan if you disagree with information provided by the pharmacy. You also have the right to request a special type of coverage determination called an “exception” if you believe:
You or your prescriber can contact your Medicare drug plan to ask for a coverage determination by calling the plan’s toll-free phone number on the back of your plan membership card, or by going to your plan’s website.
You or your prescriber can request an expedited (24 hour) decision if your health could be seriously harmed by waiting up to 72 hours for a decision. Be ready to tell your Medicare drug plan:
See your plan materials or call 1-800-Medicare for more information. Recorded and live help available 24 hours a day, seven days a week.