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Complaints Grievances and Appeals

Appeals Submission Tool

Because we, Virginia Premier, denied your request for coverage of (or payment for) a particular service, you have the right to ask us for an appeal of our decision. You have 60 days from the date of our Integrated Denial Notice or Denial of Medicare Prescription Drug Coverage to ask us for an appeal.

Who May Make a Request: You or your provider may ask us for an appeal on your behalf. If you want another individual, such as a family member or friend, to request an appeal for you, that individual must be your representative. Contact us to learn how to name a representative.

Note: All fields marked with an asterisk (*) are required.


Person Making Request
First
Last

Member's Address

0 of 8 max characters

Complete the following section ONLY if the person making this request IS NOT the member or provider:

First
Last
Requestor's Address

Representation documentation for requests made by someone other than member or the member’s provider:

Attach documentation showing the authority to represent the member (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact your plan or 1-800-Medicare.

Authorization of Representation Form CMS-1696

One file only.
8 MB limit.
Allowed types: doc docx pdf.
Accepted file types: doc,docx, pdf

Prescription drug or service you are requesting

Provider's Information

First
Last

Address

Important Note: Expedited Decisions

If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

For Part D please allow

  • 72 hours — expedited (fast) requests
  • 7 calendar days — standard requests

For Part C please allow

  • 72 hours — expedited (fast) requests
  • 30 calendar days — standard requests or 60 calendar days — standard payment requests.

Expedited appeal requests can be made by phone at 1-877-739-1370

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS

One file only.
8 MB limit.
Allowed types: doc docx pdf.
Accepted file types: doc, docx, pdf