HAP

Appeals

If we ever deny your request for a coverage decision or payment,
you have the right to request an appeal.

How to request an appeal.

How you make your appeal, and how long we have to respond, depends on whether you are appealing a decision about future care or care you have already received and whether you are appealing a decision about medical benefits or prescription drug benefits.

If you are appealing a decision about payment for care you have already received:

  • You must file this type of appeal in writing.
  • For appeals involving payment medical benefits, we have up to 60 days to respond after we receive your request.
  • For appeals involving prescription drug benefits, we have up to seven (7) calendar days to respond after we receive your request.
If you are appealing a decision about future care (care you have not already received):
  • You may request either an expedited or a standard appeal. An expedited appeal is for urgent situations where waiting for a standard decision could seriously harm your health or your ability to function.
  • You may request an expedited appeal orally or in writing.
  • You must request a standard appeal in writing.
  • For expedited appeals involving medical care, we have up to 72* hours to respond after we receive your request.
  • For standard appeals involving medical care, we have up to 30* calendar days to respond after we receive your request.
  • For expedited appeals involving prescription drug benefits, we have up to 72 hours to give you a decision.
  • For standard appeals involving prescription drug benefits, we have up to seven (7) calendar days to give you a decision.
If we deny your request for a medication or payment for a medication that you have already received, you may also request an appeal. To make that request, use this form: Request for Redetermination of Part D Drug Denial (PDF).

Where to file your appeal.

You must file your appeal with our Customer Service department by one of the following methods:

By phone:

HAP Senior Plus
(313) 664-7015 or (800) 801-1770 toll-free

TTY: 711

Alliance Medicare PPO
(313) 664-9050 or (888) 658-2536 toll-free

TTY: 711

Office hours:
Monday through Friday, 8 a.m. to 8 p.m.
Saturday, 8 a.m. to noon.
At all other times, you may access our Interactive Voice Recording system at the same number and leave your name and phone number.
A HAP Medicare Customer Service Representative will return your phone call the next business day.

Extended hours from Oct. 1 through Feb. 14: seven days a week, 8 a.m. to 8 p.m.
We will be open on Saturdays, from 8 a.m. until 12:00 p.m., from February 15 through March 31

By fax:

(313) 664-5866

In writing:

Health Alliance Plan
ATTN: Appeal and Grievance Department

2850 W. Grand Blvd

Detroit, MI 48202

By email:

msweb1@hap.org

Appointing a representative

You have the right to appoint someone to act on your behalf and request a coverage determination, as well as file a grievance or appeal. The person you name would be your appointed representative. If you want someone to act for you, then you and that person must sign and date the Appointment of Representative form (PDF) * Health Alliance Plan
ATTN: Medicare Advantage Grievances

2850 W. Grand Blvd

Detroit, MI 48202

Provider – Waiver of Liability

To file an appeal, a noncontracted physician or other non-contracted provider, who has furnished a service to the enrollee, must complete and submit the Waiver of Liability form with their appeal request. This form is required by Medicare and must be received before we can begin looking at the appeal. See the attached Waiver of Liability Statement (PDF).

You must have Adobe Reader to download PDF files. Download for free. (You are leaving a Medicare-approved site)

*The time to complete standard service and fast requests may be extended by up to 14 days if we need more information and the extension is in your best interest. if we take an extension, we will notify you in writing of the reason we need more time. You may file an expedited grievance if you disagree with our decision to take an extension. You may also request a 14 day extension if you need more time to provide us with additional information.

If you have a complaint or a problem, contact us right away. We may be able to resolve your complaint or approve a request over the phone.

You may also refer to Chapter 7 or Chapter 9 in your Evidence of Coverage , titled: What to do if you have a problem or complaint (coverage decisions, appeals, complaints). If you prefer to contact Medicare, you can call (800) Medicare (800-633-4227) or TTY/TDD (877) 486-2048, 24 hours a day, seven days a week. Or you can file a complaint at the Medicare website (You are leaving a Medicare-approved site) . The Office of the Medicare Ombudsman (OMO) (You are leaving a Medicare-approved site) can help you.

 
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