AAA

Coverage Requests, Grievance and Appeal

Part D or Pharmacy Coverage Determination

A coverage determination is a request by you, your doctor or an authorized representative for a prescription drug. This can be a request for prior authorization, a request for a drug that is not listed on our formulary, a request for a quantity of a drug greater than what we allow, a request for an exception to our step-therapy requirements, or a request to pay a lower cost share/copayment.

How to file a Part D or Pharmacy Coverage Determination

To file a request you can:

You may the following forms for your convenience:

Medicare Member Drug Request Form

Request for Medicare Prescription Drug Coverage Determination Instructions

Medicare AssuredSM  Drug Exception Form

1. Send us a request by fax to: 

  • Medicare: 1-888-447-4369

2. Mail in a request to:

Gateway Health
Attn: Pharmacy Department
P.O. Box 22158
Pittsburgh, PA 15222

3. Call us at the number listed on your membership card.

*Please remember to include what drug you are requesting, what diagnosis you are requesting it for, any drugs you have tried that didn’t work, and supply all medical records that support your request.

Part C or Medical Services Prior Authorization Request

Some of our services may require prior authorization. This means your doctor must first ask us if we will cover the procedure and may be required to provide documentation showing that it is medically necessary for you to receive these services.

How to request a Part C or Medical Services Prior Authorization Request

To file a request you can:

Note: For the following please contact:

  • Dental: 1-866-568-5467 
  • Vision: 1-800-685-5209 
  • Pharmacy: See Part D or Pharmacy Coverage Determination above.

For all others:

1. Send us a request by fax to: 

Type of Request  Medicare
Durable Medical Equipment 1-866-263-0324
Therapy/Chiropractic Care 1-888-245-2063
Inpatient(ELECTIVE)/NON Participating Exception/Ambulatory 1-888-245-2015
Skilled Nursing, Long Term Acute, Rehabilitation 1-800-685-5231
ACUTE Inpatient Admission 1-888-245-2034
Behavioral Health 1-888-245-2027
Maternity 1-855-888-8252

2. Mail in a request to:

Gateway Health
Attn: UM Department
444 Liberty Avenue
Pittsburgh, PA 15222

3. Call us at:

  • Medicare: 1-800-685-5207

*Please remember to include what you are requesting and supply all medical records that support your request.

Part D (Prescription Drug) Grievances and Appeals

GRIEVANCES
A grievance is any complaint or dispute, other than one that involves a request for coverage, expressing dissatisfaction with the operations, activities or behavior of Gateway HealthSM (“Gateway”) including its vendors or with the quality of care or service received from a Gateway Health Plan Medicare Assured® provider even if you don’t want us to take action against the provider.

A grievance may be filed by a member and/or his or her authorized representative by phone or in writing and must be filed no later than sixty (60) calendar days after the event or incident that precipitates the grievance (causes you to be unhappy).  A Gateway employee reviews all grievances as quickly as a member’s health condition requires, but no later than thirty (30) days from when the grievance is received.

To file a grievance, you may use this form: Member Grievance Form (pdf).

Note: If you are a provider with an issue you must contact provider services.

To file a complaint/grievance:

1. Call us at:

  • 1-800-685-5209 in Pennsylvania (TTY users: 711)
  • 1-888-447-4505 in Ohio (TTY users: 711)
  • 1-855-847-6430 in North Carolina (TTY users: 711)
  • 1-855-847-6380 in Kentucky (TTY users: 711)

2. Send us a request by fax to:

  • Member: 412-255-4503

3. Mail in a request to:

Gateway Health
Attn: Member Appeals Department
P.O. Box 22278
Pittsburgh, PA 15222

4. You can request a grievance/complaint by secure email.  To login and set up an account to submit a request by email, download the instructions here.  You may want to print the instruction page.

APPEALS

An appeal refers to any of the procedures that deal with the review of adverse coverage determinations (meaning where we denied coverage) made by Gateway regarding the benefits under a Part D plan that a member or their prescriber believes that he or she is entitled to receive.  An appeal can also be filed to dispute any amounts a member must pay for drug coverage.  Except when the time filing time frame is extended, the request must be filed within sixty (60) calendar days from the date of the notice of the Coverage Determination.  These procedures are called Redeterminations by Gateway and Reconsiderations at the Independent Review Entity (IRE), Administrative Law Judge (ALJ), Medicare Appeals Council (MAC) or judicial review levels of review.

If Gateway denies a request for coverage of a Part D drug, in full or in part, the member and/or authorized representative or physicians and other prescribers (upon providing notice to the member) may ask Gateway to review the denial by requesting a Redetermination (Appeal).  A request for a Redetermination (Appeal) can be made by phone or in writing to Gateway.  Gateway will review a request for Standard Redetermination as quickly as the member’s health condition requires, but no later than seven (7) calendar days from the date the request was received.  If the Redetermination decision is not entirely in the member’s favor, the decision notice will explain the member’s right to request the review by the Independent Review Entity (IRE).  The IRE will review the facts of the case and decide if Gateway’s decision was correct.  There are other appeal options that may be available after the IRE level of review, depending on the value of the drug in dispute.

How to file a complaint with Medicare

You are now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the link below. The Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program. If you have any other feedback or concerns, or if this is an urgent matter, please call 1-800-MEDICARE (1-800-633-4227). TTY/TTD users can call 1-877-486-2048.

Medicare Compliant Form .

How to file a pharmacy appeal (Part D Redetermination)

To file a redetermination, you may use this form: Standard Redetermination Form (pdf).

To file a request you can:

1. Call us at: 

  • 1-800-685-5209 in Pennsylvania (TTY users: 711)
  • 1-888-447-4505 in Ohio (TTY users: 711)
  • 1-855-847-6430 in North Carolina (TTY users: 711)
  • 1-855-847-6380 in Kentucky (TTY users: 711)

2. Send us a request by fax to:

  • 412-255-4503

3. Mail in a request to:

Gateway Health
Attn: Member Appeals Department
P.O. Box 22278
Pittsburgh, PA 15222

You can request a Redetermination by secure email.  To login and set up an account to submit a request by email, download the instructions here.  You may want to print the instruction page.

In all cases, Please include the following information in the request:

  • Your (Member) Name
  • Your (Member) Gateway Health SM Medicare Assured® ID Number
  • Your (Member) Address
  • Your (Member) Phone Number
  • Your (Member) E-mail Address
  • Name of Drug, procedure, service or claim that has been denied
  • Your doctor’s (prescriber) name and phone number
  • Date of Service, if applicable
  • Reason for Appeal
  • Medical records, drugs you have tried that did not work, and any other information to support your request

EXPEDITED APPEALS
If applying timeframe of the Standard Redetermination process would jeopardize the member’s health, life or ability to regain maximum function, an Expedited (fast) Redetermination may be requested.  A request for Expedited Redetermination can be made by phone or in writing to Gateway.  If the member’s physician or other prescribers does not provide a statement (either verbally or in writing) supporting the need for an Expedited Redetermination, a Gateway Medical Director will review the case to decide if an Expedited Redetermination is required.  If the request for an Expedited Redetermination is granted, Gateway will notify the member and prescribing physician or other provider of the decision within seventy-two (72) hours of receiving the request.  If there is no supporting statement from the physician, and the Medical Director decides that an Expedited Redetermination is not needed, the request will be reviewed under the Standard Redetermination process.  Refer to Chapter 9 of the Evidence of Coverage for further details on Part D Appeals and Grievance procedures.

To file a request you can:

1. Call us at

  • 1-800-685-5209 in Pennsylvania (TTY users: 711)
  • 1-888-447-4505 in Ohio (TTY users: 711)
  • 1-855-847-6430 in North Carolina (TTY users: 711)
  • 1-855-847-6380 in Kentucky (TTY users: 711)

2. Send us a request by fax to:

  • 412-255-4503

Part C (Medical Services) Grievances and Appeals

GRIEVANCES
A grievance is any complaint, other than one that involves a request for an organization determination expressing dissatisfaction with any aspect of the operations, activities or behavior of Gateway or with the quality of care or service received from a Gateway provider, regardless of whether corrective action is requested.

A grievance may be filed by phone or in writing and must be filed no later than sixty (60) calendar days after the event or incident that precipitates the grievance.  Gateway reviews all grievances as quickly as a member’s health condition requires, but no later than thirty (30) calendar days from when the grievance is received.

To file a grievance, you may use this form: Member Grievance Form (pdf).

Note: If you are a provider with an issue you must contact provider services. 

To file a complaint/grievance:

1. Call us at:

  • 1-800-685-5209 in Pennsylvania (TTY users: 711)
  • 1-888-447-4505 in Ohio (TTY users: 711)
  • 1-855-847-6430 in North Carolina (TTY users: 711)
  • 1-855-847-6380 in Kentucky (TTY users: 711)

2. Send us a request by fax to:

  • Member: 412-255-4503

3. Mail in a request to:

Gateway Health
Attn: Member Appeals Department
P.O. Box 22278
Pittsburgh, PA 15222

4. You can request a grievance/complaint by secure email.  To login and set up an account to submit a request by email, download the instructions here.  You may want to print the instruction page.

APPEALS
If Gateway denies all or part of a request for a service or payment of a service, member and/or his or her authorized representative, or the member’s treating physician may ask us to reconsider our decision.  This is called an appeal or a request for Reconsideration.

If Gateway denies a request for coverage of a medical service, in full or in part, the member or authorized representative or the member’s treating physician may ask Gateway to review the denial by requesting a Reconsideration.  A request for a Reconsideration can be made by phone or in writing to Gateway.  Except in the case of an extension of the filing time frame, the request for reconsideration must be filed within sixty (60) calendar days from the date of the notice of the organization determination.  Gateway will review a request for Standard Reconsiderations as quickly as the member’s health condition requires, but no later than thirty (30) calendar days from the date the request was received.  If the Reconsideration is a request for payment of a service that has already been rendered, Gateway must resolve the matter within sixty (60) calendar days of receiving the request.

If the Reconsideration decision is not entirely in the member’s favor, Gateway will automatically forward the case file to the Independent Review Entity (IRE).  The IRE will review the facts of the case and decide if Gateway’s decision was correct.  There are other appeal options that may be available after the IRE level of review, depending on the value of the services in dispute.  Please refer to Chapter 9 of your Evidence of Coverage for further details.

To file a request you can:

1. Call us at:

  • 1-800-685-5209 in Pennsylvania (TTY users: 711)
  • 1-888-447-4505 in Ohio (TTY users: 711)
  • 1-855-847-6430 in North Carolina (TTY users: 711)
  • 1-855-847-6380 in Kentucky (TTY users: 711)

2. Send us a request by fax to:

  • Member, Non-Participating Medicare Provider, and any Pre-Service Appeals: 412-255-4503
  • All Post Service appeals for Participating (Contracted Providers) and all Medicaid Providers: 855-501-3904

3. Mail in a request to:

Gateway Health
Attn: Member Appeals Department
P.O. Box 22278
Pittsburgh, PA 15222

To file a redetermination (prescription appeal), you may use this form: Standard Redetermination Form (pdf).

You can request a Redetermination by secure email.  To login and set up an account to submit a request by email, download the instructions here.  You may want to print the instruction page.

In all cases, please include the following information in the request:

  • Your (Member) Name
  • Your (Member) Gateway Health SM Medicare Assured® ID Number
  • Your (Member) Address
  • Your (Member) Phone Number
  • Your (Member) E-mail Address
  • Name of Drug, procedure, service or claim that has been denied
  • Your doctor’s (prescriber) name and phone number
  • Date of Service, if applicable
  • Reason for Appeal
  • Medical records, drugs you have tried that did not work, and any other information to support your request

If you have any questions or would like to file an expedited appeal, you may call Member Services: Click here for their contact information based on which plan you are enrolled in: http://gatewayhealthplan.com/contact-us

EXPEDITED APPEALS
If applying timeframe of the Standard Reconsideration process would jeopardize the member’s health, life or ability to regain maximum function, an Expedited (fast) Reconsideration may be requested.  A request for Expedited Reconsideration can be made by phone or in writing to Gateway.  If the member’s treating physician does not provide a statement (either verbally or in writing) supporting the need for an Expedited Reconsideration, a Gateway Medical Director will review the case to decide if an Expedited Reconsideration is required.  If the request for an Expedited Reconsideration is granted, Gateway will notify the member and the treating physician of the decision within seventy-two (72) hours of receiving the request.  If there is no supporting statement from the physician, and the Medical Director decides that an Expedited Reconsideration is not needed, the request will be reviewed under the Standard Reconsideration process.  Refer to Chapter 9 of your Evidence of Coverage for further details.

To file a request you can:

1. Call us at:

  • 1-800-685-5209 in Pennsylvania (TTY users: 711)
  • 1-888-447-4505 in Ohio (TTY users: 711)
  • 1-855-847-6430 in North Carolina (TTY users: 711)
  • 1-855-847-6380 in Kentucky (TTY users: 711)

2. Send us a request by fax to:

  • Member, Non-Participating Medicare Provider, and any Pre-Service Appeals: 412-255-4503

To obtain an aggregate number of grievances, appeals and exceptions filed with Gateway, please write to:

Gateway Health SM
Attn: Appeals Department
P.O. Box 22278
Pittsburgh, PA 15222-1222

Provider Appeals

There are two types of Provider Appeals. 

Provider Disputes are requests that are not regarding medical necessity rather are administrative in nature such as, but not limited to, disputes regarding the amount paid, appeals of denials regarding lack of modifiers, refunded claim payments due to incorrect payment or coordination of benefit issues.

Clinical Provider Appeals  are cases that are denied due to lack of prior authorization or denied based on medical necessity.

To submit a Provider Dispute, please use this contact information below.

1.       Send us a request by fax to:

  • All Providers: 1-844-207-0334

2.       Mail in a request to:

  • Non-Participating Medicare Provider, and any Pre-Service Appeals:

Gateway Health
Attn: Claims Review
444 Liberty Avenue, Suite 2100
Pittsburgh, PA 15222

To submit a Clinical Provider Appeal, please use this contact information below.

1.       Send us a request by fax to:

  • Non-Participating Medicare Provider, and any Pre-Service Appeals: 412-255-4503
  • All Post Service appeals for Participating (Contracted Providers) and all Medicaid Providers: 855-501-3904

2.      Mail in a request to:

  • Non-Participating Medicare Provider, and any Pre-Service Appeals:

Gateway Health
Attn: Member Appeals Department
P.O. Box 22278
Pittsburgh, PA 15222

  • All Post Service appeals for Participating (Contracted Providers) and all Medicaid Providers:

Gateway Health
Attn: Clinical Provider Appeals
P.O. Box 22278
Pittsburgh, PA 15222

*NOTE: If you are a non-participating provider submitting a Medicare Claim/Post Service appeal, you must submit a Waiver of Liability in accordance with Medicare Law in order for your appeal to be considered. We have attached one for your convenience for submission with your appeal.

Wavier Of Liability Form

Appointed Representatives

Members may name a relative, friend, advocate, or someone else to act on his or her behalf.  This process is called Appointing a Representative.  Other

persons may already be authorized under state law to act on a member’s behalf. In order to appoint another individual to act on a member’s behalf, both the member and the designated individual must sign and date a statement that gives this person legal permission to act as an Appointed Representative.

To appoint a representative, you may use this form: Appointment of Representative Form (pdf).

To Contact Us

Written requests for Reconsideration, Redetermination, and Grievances can be sent to this address by mail:

Gateway Health SM
Attention: Medicare Complaints Administrator
P.O. Box 22278
Pittsburgh, PA 15222

To fax your request:
412-255-4503

To make your request by telephone:
You may call Member Services, 8:00 a.m. to 8:00 p.m., 7 days a week. 

  • 1-800-685-5209 in Pennsylvania (TTY users: 711)
  • 1-888-447-4505 in Ohio (TTY users: 711)
  • 1-855-847-6430 in North Carolina (TTY users: 711)
  • 1-855-847-6380 in Kentucky (TTY users: 711) 

Forms require the Adobe Acrobat Reader installed on your system.  Most computers have this program installed.  If it is not installed on your computer, you can download it for free from Adobe.

 

Gateway HealthSM offers HMO plans with a Medicare Contract. Some Gateway Health plans have a contract with Medicaid in the states where they are offered.  Enrollment in these plans depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. These plans are available to anyone with Medicare and Medicaid.