Medical Appeals (Part C)

What is an appeal?

An appeal is a way for you to ask us to change a decision we made about your medical coverage. Making an appeal means trying to get the medical care coverage you want.

Making an appeal

You must make your appeal request within 60 calendar days from the date of the written notice we sent to you. You will get an answer within 30 calendar days for items and services and within seven calendar days for Part B drugs. We may extend this timeframe by 14 calendar days for items and services if it is in your best interest. We cannot extend the time frame for Part B drugs. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. 

Fast (expedited) appeals will be processed within 72 hours for items, services and Part B drugs. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. We may extend this time frame by 14 additional calendar days if it is in your best interest. We can't take extra time to make a decision if your request is for a Medicare Part B or Part D prescription drug.

If you would like to file an appeal, call Member Services at 1-855-735-4398 (TTY:711). Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

You may also send your written appeal by mail or fax.

Fax: 1-844-273-2671

Mail:
Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan)
Medicare Appeals and Grievances
Medicare Operations
7700 Forsyth Blvd
St. Louis, MO 63105

Please include the following:

• Your name;
• Your address and phone number;
• Your Wellcare Prime ID number;
• Your reasons for appealing; and
• Your medical records, doctor’s letter or other information that proves why you need the item or service. Call your doctor if you need this information.

If our decision is not in your favor, you may request a second level appeal within 120 calendar days after the date of our written notice.

You must appeal benefits only offered by Medicaid within 10 calendar days after you receive the Notice of Adverse Benefit Determination or the planned effective date of the action, whichever is later if you want to continue getting these services.

Please keep one copy of the fair hearing request for your information.

What is an appeal?

An appeal is a way for you to ask us to change a decision we made about your medical coverage. Making an appeal means trying to get the medical care coverage you want.

Making an appeal

You must make your appeal request within 65 calendar days from the date of the written notice we sent to you. You will get an answer within 30 calendar days for items and services and within seven calendar days for Part B drugs. We may extend this timeframe by 14 calendar days for items and services if it is in your best interest. We cannot extend the time frame for Part B drugs. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. 

Fast (expedited) appeals will be processed within 72 hours for items, services and Part B drugs. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. We may extend this time frame by 14 additional calendar days if it is in your best interest. We can't take extra time to make a decision if your request is for a Medicare Part B or Part D prescription drug.

If you would like to file an appeal, call Member Services at 1-855-735-4398 (TTY:711). Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

You may also send your written appeal by mail or fax.

Fax: 1-844-273-2671

Mail:
Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan)
Medicare Appeals and Grievances
Medicare Operations
7700 Forsyth Blvd
St. Louis, MO 63105

Please include the following:

• Your name;
• Your address and phone number;
• Your Absolute Total Care ID number;
• Your reasons for appealing; and
• Your medical records, doctor’s letter or other information that proves why you need the item or service. Call your doctor if you need this information.

If our decision is not in your favor, you may request a second level appeal within 120 calendar days after the date of our written notice.

You must appeal benefits only offered by Medicaid within 10 calendar days after you receive the Notice of Adverse Benefit Determination or the planned effective date of the action, whichever is later if you want to continue getting these services.

Please keep one copy of the fair hearing request for your information.