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Coverage Requests, Complaints & Appeals

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

Medicare Non-Formulary Drug Request Form

Medicaid Drug Request Form

  1. Send us a request by fax to:
    • Medicare: 1-888-447-4369
    • Medicaid: 1-888-245-2049
  1. Mail in a request to:
    Gateway Health
    Attn: Pharmacy Department
    444 Liberty Avenue
    Pittsburgh, PA 15222

     
  2. Call us at:
    • Medicare: 1-800-685-5215
    • Medicaid: 1-800-392-1147

*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: 1-800-392-1147
• Radiology: 1-800-424-4893
• Pharmacy: See Part D or Pharmacy Coverage Determination above.

For all others:

  1.  Send us a request by fax to:

    Type of Request 

    Medicaid

    Medicare

    Durable Medical Equipment

    1-866-263-0324

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

    1-855-888-8252

    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
    • Medicaid: 1-800-392-1147

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

Complaints, Grievances and Appeals

Complaint/Grievance

A grievance is any complaint or dispute, other than one that involves a request for coverage, expressing dissatisfaction with any aspect of the operations, activities or behavior of Gateway HealthSM (“Gateway”), including its vendors and business partners,  or with the quality of care or service received from a Gateway Health Plan® provider regardless of whether corrective action is requested. Only a member or their representative can file a complaint/grievance.  For more Medicare information click here

To file a complaint/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 : Click here for contact information based on which plan you are enrolled in: http://gatewayhealthplan.com/contact-us
     
  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

Sometimes in response to a denial of request for coverage or for claims submitted to Gateway Health Plan®, you may disagree with our initial decision. This is referred to as an “appeal”.  Appeals can be submitted by you, your doctor, or an authorized representative within the timeframe as indicated on your denial letter. For more Medicare information click here

How to file a Complaint/Grievance, pharmacy appeal (Part D Redetermination) or medical appeal (Part C Reconsideration)

To file a request you can:

  1. Call us at : Click here for contact information based on which plan you are enrolled in: http://gatewayhealthplan.com/contact-us
  1. 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
  1. 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 an appeal 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 HealthSM 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

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).

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 Health 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, or Medicare and diabetes or cardiovascular disorder or chronic heart failure.