If you receive an unfavorable Part C coverage determination (denial), you have the right to appeal. You can file an appeal within 65 calendar days from the date of the Notice of Denial of Medical Coverage (or Payment). Here is how the Part C appeals process works:

Can I file an expedited appeal on an adverse initial determination?

An expedited appeal can be requested if you believe that waiting for a decision under the standard time frame could seriously jeopardize the life or health of the member or the ability to regain maximum function.

Who can submit a Part C appeal?

You (member), a person you appoint or your physician can submit an appeal. If you want to appoint a representative to handle the appeal for you, you can find additional information on our Appointing a Representative page. 

How to file a Part C appeal 

By phone

Call CarePlus Member Services

By fax or mail

Download a copy of the Grievance or Appeal Request Form in English PDF opens in new window or Spanish PDF opens in new window, and send it to: 

Fax: 888-556-2128

Mailing address: 
CarePlus Grievance and Appeals Dept.
P.O. Box 14165
Lexington, KY 40512-4165 

Please be sure to include all supporting documentation (receipts, medical records or a letter from your doctor) along with your appeal to facilitate a comprehensive review.

Decision timeframes

After we receive your appeal, we will send you our decision in writing within the following timeframes:

• Expedited appeal – 72 hours
• Standard Part B Drug appeal- 7 calendar days
• Standard item or service appeal – 30 calendar days
• Payment appeal – 60 calendar days

Waiver of Liability

If an out-of-network doctor files an appeal for a denied claim,  he or she must include a completed a Waiver of Liability Form PDF opens in new window with the appeal request the Waiver of Liability states that the non-contracted (out-of-network) healthcare provider will not bill you, regardless of the outcome of the appeal.

If you receive an unfavorable drug coverage determination (denial), you have the right to appeal. You can file an appeal within 65 calendar days from the date of the adverse coverage determination notice. Here is how the Part D appeal process works. 

Who can submit a Part D appeal request?

You (member), a person you appoint, your prescribing doctor or other prescriber. If you want to appoint a representative to handle this request for you, you can find additional information on our Appointing a Representative page.

How to file a Part D appeal

Online

Submit an online request in English or Spanish

By phone:

Call CarePlus Grievance and Appeals:

800-451-4651 (TTY: 711)

We are open Monday – Friday, from 8 a.m. to 8 p.m. You may always leave a voicemail after hours, Saturdays, Sundays and holidays and we will return your call within one business day.

By fax or mail

Download the Request for Redetermination of Medicare Prescription Drug Denial Forms in English PDF opens in new window or Spanish PDF opens in new window, and send it to:

Fax: 877-556-7005

Mailing address: 
CarePlus Health Plans, Inc.
Attention: Grievance and Appeals department
P.O. Box 14165
Lexington, KY 40512-4165

Required documentation

Please be sure to include the following information to facilitate a comprehensive review:

• Your drug name and prescription number.
• The reason for your appeal.
• Any clinical rationale given to you by your prescriber. 
• The prescriber’s name and phone number. 

Decision timeframes

After we receive your appeal, we will send you our decision in writing within the following timeframes: 

• Expedited appeal – 72 hours
• Standard appeal – 7 calendar days
• Payment appeal – 14 calendar days