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Appeals and Exceptions: Who Can Request Coverage?

If you have Medicare, you have a right to request a coverage determination and use the Medicare appeal process. In some cases, you may need information from your health care provider or other kinds of help in order to make your request. Medicare beneficiaries may appoint a representative who can act on their behalf in the Medicare appeal process.

To name an appointed representative, call the member services number on the back of your pharmacy benefit ID card and ask to have the appropriate form sent to you, or download one from the Centers for Medicare & Medicaid Services. You and your appointed representative must both sign the form before you send it back to the plan. An appointed representative may do anything that a Medicare beneficiary can do in the Medicare appeal process, including filing a request, submitting evidence, and receiving notices from your plan.

Your appointed representative may be any willing person you choose, including a:

• relative
• friend
• doctor, pharmacist, or other health care professional
• lawyer

You may have a different appointed representative for each medicine. Medicare beneficiaries who cannot make their own medical decisions may have a court appointed guardian or conservator act on their behalf, according to state laws.