Appeals & Grievances
Grievances
A grievance is an expression of dissatisfaction with the services provided by Sterling Retiree Rx or our contracted providers. If you have a concern regarding the services provided by Sterling Retiree Rx, we encourage you to call us right away by calling our Sterling Retiree Rx Customer Care Department at 1-800-313-7667 .
Concerns can be conveyed telephonically or through correspondence. In order to exercise this right, you must file your grievance no later than 60 days after the event or incident that precipitated the grievance.
Exceptions
Members have the option to request an exception for drug coverage or tier cost sharing. For more detailed information regarding the criteria for exceptions, please call the Sterling Retiree Rx Customer Care Department at 1-800-737-7667 , Monday to Friday, 8:00 AM to 8:00 PM.
Standard Re-determination (Appeal) Process
The appeal process deals with an adverse determination regarding Sterling Retiree Rx issuing a denial for a requested drug, service, or claim payment. When submitting your appeal you may include information, which you believe, may help us with the processing of your appeal or help us rule in your favor. Upon completion of our review, a letter will be sent to you advising you of our decision.
An appeal must be filed within 60 days from the date that the determination was rendered. Upon receipt, we will review your appeal and respond within 7 days with our decision.
What to include in the Appeal Request
You should include your name, address, Member ID number, the reasons for appealing, and any evidence you wish to attach. If your appeal relates to a decision by us to deny a drug that is not on our formulary, your prescribing physician must indicate that all the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health.
Expedited Re-determination
An expedited appeal can be requested orally or in writing by the member or by a physician acting on behalf of the member. If a physician supports the request for an expedited appeal, Sterling Retiree Rx will honor this request. If a member submits an appeal without physician support, Sterling Retiree Rx will review the request to determine if it meets Medicare's criteria for expedited processing. If the plan determines that the request meets the expedited criteria, the plan will render a decision as expeditiously as the member's health requires, but not exceeding 72 hours. If the request does not meet the expedited criteria, then we will render a coverage decision with the standard predetermination time frame, 7 days.
Where to send a Grievance
Sterling Retiree Rx
Customer Care Department
144 Metro Center Boulevard
Warwick , RI 02886
Phone Number: 1-800-313-7667
Fax: 866-739-5971 |
Where to send an Appeal
Sterling Retiree Rx Medicare Appeals Department
Customer Care Department
16 International Way
Warwick , RI 02886
Phone Number: 1-800 -717-6614 or 401-734-5929
Fax: 401-739-9709
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What Happens Next
If you appeal, we will review your case and give you a decision. If any of the prescription drugs you requested are still denied, you can request an independent review of your case by a reviewer outside of your Medicare Drug Plan. If you disagree with that decision, you will have the right to further appeal. You will be notified of your appeal rights if this happens.
Contact Information
If you need information or help, call us at:
Toll Free: 1-800-313-7667
TTY: 1-800-313-7667
Other Resources To Help You
Medicare Rights Center
Toll Free: 1-888-HMO-9050
Elder Care Locator
Toll Free: 1-800-677-1116
1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048
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