Coverage Determinations, Appeals and Grievances

Lovelace has processes in place to address coverage issues, complaints and problems. If you have a coverage issues related to medical or pharmacy servicesor if you or your representative wish to file an appeal or grievance, please contact our Customer Care Center at 505-232-1883 or 1-800-7363 (or TTY at 505-232-1810 or 1-800-288-5605) Monday through Friday 8:00 a.m. to 5:00 p.m. Staff will be available to accept Part D calls Monday through Sunday from 8:00 a.m. to 8:00 p.m. Or contact us by fax at 505 262-7307. You may also contact us in writing at:

Lovelace Senior Plan or Premier Choice
Customer Care Center
P.O. Box 27107
Albuquerque, NM 87125

You have the right to make a complaint if you have concerns or problems related to your coverage or care.  “Appeals” and “Grievances” are two different types of complaints you can make:

• An “appeal” is the type of complaint you make when you want us to reconsider and change a decision we have made about what services or benefits are covered for you or what we will pay for a service or benefit.
• A “grievance” is the type of complaint you make if you have any other type of problem with Lovelace Senior Plan or Premier Choice.

APPEALS 

If we deny coverage or payment for an item, medical service, or prescription that you think we should cover or pay for, you may request an appeal.

• You can ask us to “expedite” an appeal or give you a quick decision if we denied coverage for a service.
• If we deny coverage for a drug that you think should be covered or if you think it should be covered on a different tier, you may request an “exception”.
• If you think you are being discharged from the hospital too soon, you may ask for a “Notice of Discharge and Appeal Rights.”
• If you think that your covered services in a Skilled Nursing Facility, Home Health or Comprehensive Outpatient Rehabilitation Facility are ending too soon, you may ask for a “fast track” appeal.

GRIEVANCES

If you have a complaint related to the quality of care you receive, the timeliness of services, or any other concern except for coverage or payment issues listed above, you may file a grievance.

Appeals and Grievances Information

If you or your representative want to file an appeal or grievance, you may contact the Lovelace Appeals Department at the above numbers or address.  You may also contact the Appeals Department if you want information on the number of appeals and grievances filed with the plan.

Appointment of Representative:  If you want someone to act for you on an appeal or grievance, you can appoint that person to represent you. This person could be a family member, advocate, physician, friend or anybody else.  You need to give permission to this person by you signing and dating either a Medicare or a Lovelace Appointment of Representative Form. Your representative must also sign and date the statement unless he/she is an attorney. You may use either a form that CMS provides or a form that Lovelace has developed. Fax a completed and signed copy of either form to 505- 262-7719 (toll free at 800-808-7363) or mail to Lovelace, Customer Service, 4101 Indian School Road NE, Albuquerque, NM 87110.

Medicare Appointment of Representative Form

Lovelace Appointment of Representative Form

Pharmacy Coverage Determinations and Drug Exception Requests:  You are entitled to request a coverage determination related to your pharmacy coverage benefit.  You, your representative or your prescribing physician may request a coverage determination, including a tiering or formulary exception, by contacting the Customer Care Center at 505-232-1883 or 1-800-7363 (or TTY at 505-232-1810 or 1-800-288-5605) Monday through Friday 8:00 a.m. to 5:00 p.m. Staff will be available to accept Part D calls Monday through Sunday from 8:00 a.m. to 8:00 p.m. Or contact us by fax at 505-262-7390. You may also contact us in writing at Lovelace Senior Plan or Premier Choice, Customer Care Center, P.O. Box 27107, Albuquerque, NM 87125. 

Pharmacy Coverage Determination Form

You may request a pharmacy coverage determination by telephone or by submitting a written request. You may use a copy of this form if you so desire. Mail or fax the completed form as indicated above.

LHP Prior Authorization Step Therapy and Drug Exception Form

Your physician or his/her office staff may request a pharmacy prior authorization, step therapy or non formulary drug exception request by using a copy of this form and faxing it to 505 262-7390, the fax number indicated on the form.

Pharmacy Appeals and Grievances

For detail on the pharmacy appeals and grievance process, please see Chapter 12 of your Evidence of Coverage or click on this link. 

Pharmacy Appeals Information

Medicare Redetermination Requests and Form

If you do not agree with a coverage determination decision, including a pharmacy coverage decision made, and want to appeal that decision, you, your doctor or your representative should contact Lovelace Customer Care Center at 505-232-1883 or 1-800-7363 (or TTY at 505-232-1810 or 1-800-288-5605) Monday through Friday 8:00 a.m. to 5:00 p.m. Staff will be available to accept Part D calls Monday through Sunday from 8:00 a.m. to 8:00 p.m. Or contact us by fax at 505-262-7390. You may also contact us in writing at Lovelace Senior Plan or Premier Choice, Customer Care Center, P.O. Box 27107, Albuquerque, NM 87125. You may request a standard appeal to which we will provide a response within 7 calendar days, or you may file a fast appeal if you or your doctor feel that a standard appeal could seriously harm your health or ability to function. If we determine that your appeal should be treated as a fast appeal, we will provide our decision within 72 hours. You mayuse the attached Medicare Redetermination Request Form to file your appeal..

Fraud and Abuse Program Policy Statement:
The Lovelace (LHP) Fraud & Abuse Program is dedicated to detecting, investigating, and preventing all forms of suspicious activities related to possible health insurance fraud or abuse, including any reasonable belief that insurance fraud will be, is being, or has been committed. Click here for more information.

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