Follow these steps in requesting a Part D Redetermination.

I. MEMBER INFORMATION
Please complete this section as follows:
As a SCAN member you may file a Grievance and/or Appeal or you can appointment a relative, friend, advocate, doctor, attorney, or other person to act for you. If you already have an authorized representative under state law to act for you, this person may file a Grievance and/or Appeal. If you would like to appoint a representative to file a Grievance and/or Appeal on your behalf please reference the CMS Appointment of Representation form (Form CMS-1696)

www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf

Member Name
Member ID number - This can be found on your SCAN membership card
Name of Part D Prescription
Reason you do not agree with initial Prescription drug determination
Date of initial Determination notice

If you are filing a Redetermination on behalf of a member and you want to receive a response to the Redetermination as well, please complete the following fields on the form:

Requestor Name
Requestor’s relationship to member (must submit documentation that shows authority to represent member, if other than prescribing physician)
Member/Requestor’s Address
Member/Requestor’s Phone number

II. NAME OF PRESCRIPTION DRUG REQUEST
This identifies the Part D prescription drug you are requesting a Redetermination..

III. PRESCRIBING PHYSICIAN’S INFORMATION
If a prescribing physician is requesting a Redetermination on behalf of a member; please complete the following fields on the form:

Physician Name
Medical Specialty
Physician Address
Physician Phone Number, and Physician Fax Number
Physician Office Contact Person

IV. WHEN FINISHED
Click the submit button to send your form to SCAN. We suggest that you print a copy for your records.

	Beneficiary’s Name	Medicare Number

	Description of Item or Service in Question	Date the Service or Item was Received

	I do not agree with the determination of my claim. MY REASONS ARE

	Date of the initial determination notice

	(If you received your initial determination notice more than 120 days ago, include your reason for not making this request earlier.)

	Additional Information Medicare Should Consider

	Requester’s Name	Requester’s Relationship to the Beneficiary

	Requester’s Address	Requester’s Telephone Number

		I have evidence to submit.

		I do not have evidence to submit.