Learn what an appeal is, how to file, and what to do if your appeal is denied.

What’s an appeal?

An appeal, or reconsideration, is a formal way to ask the plan to review a coverage decision about health care services and/or prescription drugs. You may ask for a review when you are not satisfied with our initial coverage decision. You may ask for an appeal if:

  • You were denied payment for services and/or covered prescription drugs you already received or paid for.
  • You do not agree with a decision to stop getting a particular service.
  • We won’t pay for a drug, item, or service you think you should be able to get.

You must make your request within 60 days from the date of the coverage decision.

Part C - Medical Appeals


You or your appointed representative (someone you name to act for you) may ask for a medical appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you with an Appointment of Representative form. Under state law, others may already be allowed to act for you. A physician who is giving you treatment may, upon giving you notice, ask for a standard reconsideration on your behalf without submitting a representative form. To obtain the total number of our grievances, appeals, or exceptions, please contact us. Get an Appointment of Representative form


  • Standard Medical Appeal

    If you are asking for reimbursement for medical care you have already received, this is a Standard Medical Appeal. We will give you an answer within 60 days of your filing.

  • Standard Medical Pre-Service Appeals

    If you are asking for coverage for medical care you have not yet received, this is a Standard Medical Pre-Service Appeal. We will give you an answer within 30 days of your filing. We can take up to 14 more days if you ask for more time or if we need information that may help you. If we decide to take extra time, we will tell you in writing.

  • Fast Medical Appeals

    You or your doctor (without an appointment of representative form) can request a Fast Medical Appeal by phone or mail if waiting for a Standard Appeal could harm your health or your ability to function. You can get one:

    • For medical care you have not yet received

    • If you're getting Medicare services from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice, and you think your Medicare-covered services are ending too soon. Your doctor will give you a notice before your services end that will tell you how to ask for a Fast Medical Appeal in your area. An independent reviewer, called a Quality Improvement Organization (QIO), will decide if your services should continue.

We will give you an answer within 72 hours. We can take up to 14 more days if you ask for more time or if we need information that may help you. If we decide to take extra time, we will let you know.


Call

1-866-393-5366 or 305-559-5366 (TTY 711).

We’re here from 8:00 a.m. to 8:00 p.m., seven days a week, from October 1 through March 31 and Monday to Friday, the rest of the year.

Email

MemberSupport@lmchealthplans.com

Write

Leon Medical Centers Health Plans
Attn: Appeals
PO Box 66-9440
Miami, Florida 33166

Fax

305-229-7500


Part D - Pharmacy Appeals


You, your representative, or your prescriber may request a pharmacy appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you with an Appointment of Representative form. Under state law, others may already be allowed to act for you. To obtain the total number of our grievances, appeals, or exceptions, please contact us.

You must make your request within 60 days from the date of the coverage determination. A coverage determination is the first decision made by your Medicare drug plan (not the pharmacy) about your drug benefits.


  • Standard Pharmacy Appeals

    If you’re asking for a Standard Appeal for prescription drugs, we will give you an answer within 7 calendar days of receipt of your request.

  • Fast Pharmacy Appeals

    You may also ask for a Fast Appeal for prescription drugs, if waiting for a Standard Appeal could seriously harm your health or your ability to function. If you are asking for a Fast Appeal for prescription drugs, we will give you an answer within 72 hours of receipt of your request.


Call

1-866-393-5366 or 305-559-5366 (TTY 711).
We’re here from 8:00 a.m. to 8:00 p.m., seven days a week, from October 1 through March 31 and Monday to Friday, the rest of the year.
Member Services also has free language interpreter services available for non-English speakers.

Email

MemberSupport@lmchealthplans.com

Write

Leon Medical Centers Health Plans
Attn: Appeals
PO Box 66-9440
Miami, Florida 33166

Fax(regular & expedited)

1-866-593-4482


What if my appeal is denied?

If we deny your appeal for medical care, we will send you an explanation of our decision in writing, and your case will automatically be sent to Level 2 of the appeals process. At Level 2, the Independent Review Organization reviews our plan's decision to decide if it is correct or if it should be changed. If you had a Fast Track Appeal at Level 1, you will have a Fast Track Appeal at Level 2. The time frames for a Fast and Standard Appeal at Level 2 are the same as for the initial appeal.

If our plan denies your appeal for a Part D prescription drug, you will need to choose whether to accept this decision or appeal it to Level 2. The notice we send you denying your Level 1 Appeal will include instructions on how to make a Level 2 Appeal. They will tell you who can make the appeal, deadlines you must follow, and how to reach the review organization.

At Level 2, the Independent Review Organization reviews our plan's decision and decides if it is correct or if it should be changed. If you had a Fast Appeal at Level 1, you will have a Fast Appeal at Level 2. The time frames for a Fast and Standard Appeal at Level 2 are the same as for the initial appeal. If the answer to your Level 2 Appeal is no, it means the review organization agrees with our decision not to approve your request.

Appeal Levels 3, 4, and 5

To reach a Level 3 Appeal, the dollar value of the drug or medical care you are asking for must meet a minimum amount. If the dollar value is too low, you cannot make another appeal and the decision at Level 2 is final. The notice you get denying your Level 2 Appeal will tell you if the dollar value is high enough to move on to Level 3. If you qualify for a Level 3 Appeal, an Administrative Law Judge will review your appeal and make a decision. If you do not agree with the decision the judge makes, you can move on to a Level 4 Appeal. At the Level 4 Appeal, the Medicare Appeals Council, who works for the federal government, will review your appeal and give you an answer. If you do not agree with the decision at Level 4, you may be able to move on to the next level of review.

A Level 5 Appeal is reviewed by a judge at the Federal District Court. This is the last stage of the appeals process. To learn more about these additional levels of appeal, see the Chapter named "What to do if You Have a Problem or Complaint" in your Evidence of Coverage.

Questions and Complaints

If you have questions about appeals, exceptions, and/or would like to make a complaint, or if you want to get an aggregate total of appeals/exceptions/grievances filed with the plan, please call us at the numbers listed for your plan above.

To submit a complaint to Medicare, complete the Medicare Complaint Form