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Forms

Member Forms

General Authorization for Release of Confidential Information

  • This form is required by Piedmont if a member would like his or her personal health care information shared with another party.

Prescription Reimbursement Standard Claim Form

  • In the event that a member overpays for a prescription, he or she will need to complete the Prescription Reimbursement Standard Claim Form.

Prescription Drug Mail Order Form

  • The Prescription Drug Mail Order form is available only for certain kinds of drugs. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition.

  Appointment of Representative Form

  • If a beneficiary would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on his or her behalf, the beneficiary and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request.

  Request for Medicare Prescription Drug Coverage Determination Form

  • It is your right to be paid back by our plan whenever you’ve paid more than your share of the cost for drugs that are covered by our plan. A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a prescription drug coverage determination or exception request.

  Request for Redetermination of Medicare Prescription Drug Denial

  • In the event that Piedmont has denied the member’s request for coverage and or payment for a prescription drug, the member has the right to ask for a redetermination (appeal) of our decision.

Medicare Complaint Form

  • If the member would like to provide feedback to Medicare in regards to Piedmont Medicare Advantage the member may do so with this form.

  Attestation of Eligibility

  • Typically, you may enroll in a Medicare Advantage plan only during the Annual Enrollment Period (AEP). There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of the AEP. The Attestation of Eligibility lists other qualifying Special Enrollment Periods.

 

Provider Forms

Medical Paper Claim Form

  • When a member receives service, the provider provides Piedmont with the following form so that we may process the member’s benefits.

  Coverage Determination Request Form for Physicians (Medicare Part D Coverage Determination Request Form )

  • This form was developed by AHIP, the AMA, and other entities to provide prescribers with a form to be used to request a coverage determination or exception, support a tiering or formulary exception request, or request prior authorization. It may be completed by an enrollee's prescriber and mailed or faxed to the enrollee’s plan sponsor.

 

Piedmont Medicare Advantage is a PPO plan with a Medicare contract. Enrollment in Piedmont Medicare Advantage depends on contract renewal. Out-of-network/non-contracted providers are under no obligation to treat Piedmont Medicare Advantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

 

H1659_Web2018Upd <pending approval>
Updated 11/13/2017