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Redeterminations (Appeals)

If we make a coverage determination and you are not satisfied with our decision you can “appeal” the decision. Requesting an appeal means asking us to reconsider – and possibly change – our decision. An appeal is also known as a plan “redetermination”. If we deny coverage or payment for an item or prescription that you think we should cover or pay for, you may request an appeal.

How do I request an Appeal?

You, your doctor or prescriber, or appointed representative may request an appeal by phone, mail or fax. Your redetermination can be requested 24 hours a day, 7 days a week.  You have 60 days from the date of denial of your coverage determination to ask us for a redetermination. 

Call Us!     1-855-586-2573 (TTY: 711)

When you mail or fax your request, we recommend filling out then printing our Redetermination Request Form to ensure you are providing all the information needed for us to process your request. The denial notice you received from our coverage determination will also include a pre-printed copy of the Redetermination Request Form.

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 Hours of Operation: 24 hours a day, 7 days a week

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Email: GAICHelp@primetherapeutics.com

Mail the Request:

Granite Alliance Insurance Company
P.O. Box 64810
St. Paul, MN 55164

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Fax:  1-888-656-8099

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What happens when I request an Appeal?

Once Granite Alliance receives a redetermination (appeal) request, we review the original coverage determination we made to check to see that we were following all the rules properly. We may reach out to your doctor or prescriber to get additional information. Your appeal will be handled by a different reviewer than the person who made the original decision. This process ensures that we give your request a thorough review, independent of the original review.

If your request is a standard appeal, once we receive your request, we must give you our answer within seven (7) calendar days. We will give you our decision sooner if you have not yet received the drug and your health condition requires us to do so.

If you are appealing a decision, we made about a drug you have not yet received and you and your doctor or prescriber believe that your health requires it, you should ask for a “fast” appeal. A “fast” appeal is also called an “expedited redetermination”. For a “fast” appeal, we must give you our answer within 72 hours after we receive your request.

If we are unable to make the timeframes indicated above, we will automatically forward your request to an Independent Review Organization (IRE) to decide on our behalf.

What if I still do not agree with the decision of my appeal?

When you submit a request for an appeal that is considered a “Level 1” appeal. If we say no to your appeal, you can choose whether to accept our decision or continue by making another appeal. This second appeal is called a “Level 2” appeal. Level 2 appeals are reviewed by an independent review entity (IRE) which has a contract with the Centers for Medicare & Medicaid Services (CMS). To submit a Level 2 appeal, you, your representative, your doctor, or prescriber must contact the IRE and ask for a review of your case. If we deny your Level 1 appeal, the written notice we send you will include the IRE information along with a reconsideration request form. You must send your written request to the IRE within 60 calendar days of the date we notified you of our decision. After it receives your appeal the IRE will respond to your request within seven (7) calendar days (for standard requests) or 72 hours (for expedited requests).

Are there additional levels of appeal?

If the IRE says no to your Level 2 appeal (called upholding the decision), you can continue to request reviews at additional levels of appeal:

If my Appeal is approved, what happens?

If during any level of appeal your request is approved, we must provide the coverage you have requested as quickly as your health requires. The timeframe for our response depends on the level of appeal for your request. 

If you have already paid for the drug, we are required to send payment to you within 30 calendar days after we received your favorable appeal decision.

For additional information on the appeals process, please review Chapter 6 of your Evidence of Coverage.

Last Updated Date: ​​01/01/2024

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