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Proper procedures for appealing adverse coverage decisions

January 18, 2018

According to the Centers for Medicare & Medicaid Services' regulations, when an authorization request for admission to a post-acute facility (i.e., Long-Term Acute Care Facility, Skilled Nursing Facility, and Acute Rehabilitation Facility) results in an adverse plan decision and new clinical evidence is available, you must submit it as a member appeal within 60 days of the initial decision. Additional clinical information cannot be presented to the Clinical Services – Utilization Management department for review. An appeal may be submitted within 180 days from the receipt of the adverse decision. Note: This procedure applies to both commercial and Medicare Advantage members.

Appeals for denials can be submitted as outlined below.

Commercial members

  • Mail:
    Member Appeals
    P.O. Box 41820
    Philadelphia, PA 19101-1820
  • Fax: 1-888-671-5274
  • Call: 1-888-671-5276

Medicare Advantage members

  • Mail:
    Medicare Member Appeals & Grievances
    P.O. Box 13652
    Philadelphia, PA 19101
  • Fax: 215-988-2001
  • Call the Member Help Team:
    • Keystone 65 HMO: 1-800-645-3965 (TTY/TDD: 711)
    • Personal Choice 65SM PPO: 1-888-718-3333 (TTY/TDD: 711)

If new evidence becomes available after the 60-day period, a new authorization request should be submitted using the Authorizations transaction on the NaviNet® web portal or by calling 1-800-ASK-BLUE and following the prompts for Authorizations.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.


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