For more information, see your plan’s Evidence of Coverage (EOC). Contact Member Services at 1-877-232-7566 (TTY: 711) to learn more about our grievance and appeal numbers.
Coverage decisions are the first decision made by the plan on the medical care you are requesting or the drugs(s) or payment you need.
A standard coverage decision for medical care means we will give you an answer within 14 calendar days after we receive your request. A fast coverage decision means we will answer within 72 hours.
A standard coverage decision for drugs means we must give you our answer within 72 hours after we receive your request. For a fast coverage decision about the drug(s) or payment you need, we must give you our answer within 24 hours.
If you receive Extra Help from Medicare to pay your Medicare prescription drug plan costs, your monthly premium will be reduced.
To request a coverage decision for medical care, drugs, or payment, you, your appointed representative, or physician should contact us by telephone, fax, or mail at these numbers or addresses:
You, your prescriber, or member representative may ask for a coverage decision via secure email outlined in the CMS drug coverage determination form.
Mail or fax us a copy of the itemized prescription receipt along with a copy of the register receipt if available. Note: the register receipt alone is not adequate because it doesn’t have all pertinent information needed for reimbursement.
The itemized receipt should contain the following information:
Mail to:
Dean Health Plan
Attn: Part D Member Claims Department
P.O. Box 1039
Appleton, WI 54912-1039
Fax: 1-855-673-6507
If you are requesting reimbursement, complete the patient's request for medical payment form. Mail the form along with your bill and documentation of any payment you've made. It is a good idea to make a copy of the bill and receipts for your records.
For Medicare Part C medical payment requests:
Dean Health Plan Medicare Advantage
PO Box 853937
Richardson, TX 75085-3937
For Medicare Part D drug payment requests:
Dean Health Plan
Attn: Part D Member Claims Department
PO Box 1039
Appleton, WI 54912-1039
An appeal means we will review an unfavorable coverage determination.
A grievance is any complaint or dispute (dissatisfaction) other than one involving an organization determination. It is different from a coverage determination request; it usually will not involve coverage or payment for Part D drug benefits or Part C medical benefits.
In most cases, you only have 60 calendar days from an event to file a grievance or appeal. You may be eligible to file a grievance or appeal after 60 calendar days when you provide a good cause reason for missing the deadline. If we do not accept your good cause reason, we will notify you in writing.
You can file an appeal if you want us to reconsider a decision we have made about your Part D prescription drug benefits or cost sharing associated with your Part D drug coverage.
You can file an appeal if you want us to reconsider a decision we have made about your Part C medical prior authorization or Part C medical claim or cost share associated with your Part C medical coverage.
You, your prescriber, or member representative may ask for a redetermination (appeal) using the Medicare redetermination request form.
To check status or to request a standard or fast grievance or an appeal, you, your appointed representative, or your prescribing physician should contact us by telephone, fax, mail, or hand-deliver at these numbers or addresses: