Part D appeals and grievances

Part D appeals

If you, your doctor, or your representative disagree with the outcome of the initial coverage determination, you can appeal the decision by requesting a redetermination.

Ways to file an appeal for AmeriHealth Rx PPO members

• Call 1-866-569-5190 (TTY/TDD: 711) for expedited appeals only. Calls to this number are free. Representatives are available seven days a week, from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
• Complete the secure online Coverage Redetermination Request Submission Form
• Download and print the Coverage Redetermination Request Form to send by fax or mail.
  • Fax: 1-888-289-3008
  • Mail to:
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If our answer is yes to part or all of what you requested:

• If we approve a coverage request, we must provide the coverage we have agreed upon as quickly as your health requires, but no later than seven calendar days after we receive your appeal.
• If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.
• If we approve an expedited (or fast) coverage request, we must provide the coverage we have agreed upon as quickly as your health requires, but no later than 72 hours after we receive your appeal.

If our answer is no to part or all of what you requested:

• We will send you a written statement that explains why we said no and how to appeal our decision.

Part D appeals process

For more information on Part D appeals, please reference your plan's EOC or contact the Member Help Team.

• 2025 AmeriHealth Medicare PPO EOC

Part D grievances

A grievance is a formal complaint or dispute. You can file a grievance if you are dissatisfied with any aspect of the operations, activities or behavior of AmeriHealth or its network pharmacies. If you disagree with a coverage determination decision, please see the Part D Appeals section above.

You will receive a resolution within 30 days of filing a grievance. Once a decision is rendered, we will notify you.

Ways to file a complaint for AmeriHealth Rx PPO

• Call: 1-866-569-5190 (TTY/TDD: 711). Calls to this number are free. Representatives are available seven days a week, from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
• Fax: 1-888-289-3008
• Write:
  Medicare Member Appeals Unit
  PO Box 13652
  Philadelphia, PA 19101-3652

Part D grievances process

For more information on Part D grievances, please reference your plan's EOC or contact the Member Help Team.

• 2025 AmeriHealth Medicare PPO EOC

To obtain an aggregate number of grievances, appeals, and exceptions filed with AmeriHealth, please contact the Member Help Team.

Appointment of a representative

If you want someone other than your provider to act on your behalf, please complete the Appointment of Representative (AOR) form.

If you are filing an AOR for a coverage determination, please submit the form to:

Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-800-527-0531

If you are filing an AOR for an appeal or a grievance, please submit the form to:

Medicare Member Appeals Unit
PO Box 13652
Philadelphia, PA 19101-3652

Contact information

Members and providers who have questions about the exceptions and appeals processes, or would like to inquire about the status of a coverage determination or appeal request, please contact the Member Help Team.

To obtain an aggregate number of grievances, appeals, and exceptions filed with AmeriHealth, please mail a written request to:

Medicare Member Appeals Unit
PO Box 13652
Philadelphia, PA 19101-3652

If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.

 

 

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Website last updated: 7/2/2025