Important information about your appeal rights
There are two kinds of appeals that you may request from AmeriHealth Caritas VIP Care Plus (Medicare-Medicaid plan):
If you don't agree with a decision we make about Medicare or Medicaid services or payment, you have the right to appeal to AmeriHealth Caritas VIP Care Plus. The steps are outlined below. We will review our decision and let you know what we have decided. We'll give you a written decision on a standard appeal for services within 30 calendar days after we get your appeal (seven calendar days for appeals related to medications). Our decision might take longer if you ask for an extension, or if we need more information about your case. We'll tell you if we're taking extra time and will explain why more time is needed. If your appeal is for payment of a service you've already received, we'll give you a written decision within 60 calendar days.
Fast (expedited) appeal
We'll give you a decision on a fast (expedited) appeal within 72 hours after we get your appeal. You can ask for a fast appeal if you or your provider believe your health could be seriously harmed by waiting up to 30 calendar days for a decision. Please note: we will automatically give you a fast appeal if a provider asks for one for you or supports your request. If you ask for a fast appeal without support from a provider, we'll decide if your request requires a fast appeal. If we don't give you a fast appeal, we'll give you a decision within 30 calendar days (or seven calendar days for drug appeals).
How to ask for an appeal with AmeriHealth Caritas VIP Care Plus:
Step 1: You, your representative, or your provider must ask us for an appeal within 60 days of the date on your denial notice for a service authorization. Your appeal request must include your:
- Member ID number.
- Reasons for appealing and services you want to appeal.
- The date you received or plan to receive the service.
- Evidence you want us to review to make our decision, such as medical records, a letter from your provider, or other information that explains why you need the item or service. You may call your provider for this information.
- You can also use the Appeal Request Form (PDF) or the Request for Redetermination of Medicare Prescription Drug Denial to file an appeal with AmeriHealth Caritas VIP Care Plus.
- If your request is made by a family member, friend, or other party, the appeal requests must include a filled-out Appointment of Representative Form (PDF) or an equivalent written notice. Follow these instructions for completing the Appoinment of Representative Form.
Step 2: You have choices about how to appeal. You can call us or mail, fax, or deliver your appeal request.
Call us at 1-888-667-0318 (TTY/TDD 711) or fax your request to 1-855-221-0046.
If you ask for an appeal by phone, we will send you a letter confirming what you told us.
Mail your appeal request to:
AmeriHealth Caritas VIP Care Plus
Attn: Appeals and Grievances
P.O. Box 337
Essington, PA 19029
For process or status questions, or to obtain a complete number of AmeriHealth Caritas VIP Care Plus grievances, appeals, and exceptions, please call Member Services at 1-888-667-0318 (TTY/TDD 711), 8 a.m. to 8 p.m., seven days a week.
For help with complaints, grievances, and information requests, you can also call the Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (TTY 1-877-486-2048). Or go to the Medicare website and fill out a Medicare Complaint Form. (Please note: by clicking on this link you will be leaving the AmeriHealth Caritas VIP Care Plus website.)