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An enrollee or an enrollee’s appointed representative may request an appeal (“Instructions on Appointing a Representative” for details). The prescribing physician may request an expedited redetermination without being the enrollee’s appointed representative. However, this is the only appeal that the prescribing physician may request on an enrollee’s behalf unless he/she is the enrollee’s appointed representative. How to request a Freedom Health standard redetermination: The enrollee may file a signed written request or the enrollee may call the Member Services Department to make an oral appeal. The enrollee may call toll, Monday through Friday, to 1-800-401-2740. Enrollee’s needing TTY/TDD services should call 1-800-955-8771. The request for a standard redetermination must be made within 60 calendar days from the date of the notice of the coverage determination. Freedom Health will provide every opportunity to present evidence and allegations of fact or law related to the issues in dispute, in person and in writing by telephone, fax, or hand delivery to the Freedom Health office located at: Information may be faxed to (727) 471-2108. Freedom Health will take all of the evidence submitted into account when making a decision. The plan will designate someone other than the person involved in making the initial coverage determinationo to make the redetermination. If the original denial was based on a lack of medical necessity, the redetermination will be performed by a physician with expertise in the field of medicine that is appropriate for the benefits at issue. Freedom Health will notify the enrollee in writing of its redetermination (whether favorable or adverse) as quickly as the enrollee’s health condition requires, but no later than 7 calendar days from the date Freedom health receives the request for a standard redetermination. The written notice of an adverse determination will include: (1) the specific reasons for the denial and (2) will inform the enrollee of his/her right to a reconsideration –for issues of drug coverage the letter will include a description of both the standard and expedited reconsideration process. For issues of payment the letter will include a description of the standard reconsideration process. The written notification will also include a description of the remaining options in the appeals process. How to request a Freedom Health expedited (fast) redetermination: Freedom Health will accept both oral and written requests for expedited (fast) redeterminations in the same manner as for standard redeterminations. If the oral or written request is made by a physician or supported by a physician’s oral or written statement, Freedom Health will always grant the request to expedite if the physician indicates that the enrollee’s life, health, or ability to regain maximum function could be jeopardized by applying the standard time frame for processing the redetermination request. If the plan denies an enrollee’s request for an expedited redetermination, the standard redetermination process will be followed and Freedom Health will notify the enrollee orally of the denial and the enrollee’s rights. A written notice of the denial for an expedited redetermination will be sent to the enrollee within 3 calendar days of the oral notification. Expedited redeterminations will be by the Plan made no later than 72 hours after receipt of the request. Any request for additional medical information will be made within 24 hours of receiving the initial request. Any adverse redetermination redetermination (in whole or in part) will be made as expeditiously as the enrollee’s health condition requires, but no later than 72 hours from the date and time of receipt of the request. If the enrollee’s prescribing physician filed the request on behalf of the enrollee, Freedom Health will notify the enrollee and enrollee’s prescribing physician. The initial notification will be oral with a written notification within 3 calendar days of the oral notification. The adverse redetermination written response will include: (1) the specific reasons for the denial and (2) inform the enrollee of his/her right to a reconsideration – including for issues of drug coverage a description of both the standard and expedited reconsideration processes and for issues of payment a description of the standard reconsideration process. The written notification will include a description of the remainder of the appeals options. For more details on the formal Freedom Health redetermination process and the remainder of the appeals options, please click the link below for the current Explanation of Coverage. The appeals process for Part D benefits can be found in Section 12.
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