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Important Member Forms

It is our pleasure to serve you.

If you personally paid for a covered medical service or OTC item, fill out this form to receive timely reimbursement:

Member Reimbursement Form (last updated 1/25/17)

Enroll in Centers Plan for Medicaid Advantage Plus (HMO SNP) – Last updated 5/2/2019

Medicare Transition Drug Policy Overview – Last Updated 07/06/2015

See Our Prescription Drug Transition Policy  – Last updated 04/18/2014

Standard Coverage Determination
To ask for a standard decision, you, your doctor or your appointed representative should call us at 1-888-266-7460, 7 days a week, from 8 am to 8 pm (for TTY, call 711 or 1-800-421-1220). Or, you can mail a written request, or completed Request for Coverage Determination Form to:

MedImpact Healthcare Systems, Inc
Attention: Appeals/Grievance Department
10181 Scripps Gateway Ct
San Diego, CA 92131

Or you may fax it to: 1- 858-790-6060

In the event that you need to appoint a representative regarding a grievance, request a coverage determination or an appeal, or to make complaints, the following form is also available on the Medicare and Medicaid Services (CMS) website:

How to Appoint a Representative - Last updated 03/07/19

CMS Appointment of Representative Form  – Last updated 03/05/2019

CMS Appointment of Representative Form -Spanish - Last updated 03/05/2019

CMS Appintment of Representative Form- Large Print - Last updated 03/05/2019

CMS Electronic Complaint Form – Last updated 11/19/2014

Best Available Evidence (BAE) – Last updated 11/19/2014

 

Medicare Disclaimer 

 

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Last modified: May 7, 2019