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Requirements for submitting expedited appeals on behalf of Medicare Advantage members

September 20, 2017

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As you may know, the Centers for Medicare & Medicaid Services (CMS) defines expedited appeal requests as those that could seriously jeopardize the life or health of the member or the member?s ability to regain maximum function. Expedited appeal determinations generally must be resolved within 72 hours, which makes it critical that we receive all relevant medical documentation.

To process expedited member appeals efficiently, especially on weekends and holidays, it is imperative that we receive legible, up-to-date information about the member. This includes the latest medical records and any other information needed to review a determination. A telephone number where you can be reached is critical, especially if the appeal occurs after hours or on the weekend. Appeals can be submitted by calling Customer Service at 1-800-645-3965 for Keystone 65 HMO members and 1-888-718-3333 for Personal Choice 65SM PPO members, or by sending a fax to 215-988-2001.

Also, if you are filing an appeal on behalf of a member and wish to withdraw the appeal, please send written confirmation as required by CMS.

We greatly appreciate your cooperation so that we may ensure that appeals are processed timely and that plan decisions are an accurate reflection of the member?s medical situation.

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