1) please include only one member per request

2) include only one prescription per request

3) include relevant supporting clinical documentation

4) check form for missing information and accuracy, and fax to (469) 592-6460.

You have the right to appeal the decision. You must appeal the decision in writing within the 180 days following the date of a communication. You may also work with your patient to evaluate therapeutic alternatives when appropriate. If you elect to appeal, please make sure to include all pertinent clinical information regarding your health and medication history that should be evaluated to render a decision. Insufficient information could postpone a decision or lead to a subsequent denial.

Standard (15 days) – You can request a standard appeal, which means that 15 days after receiving your request for an appeal, we must inform you of our decision.

Fast (48 hours) – You can request an expedited appeal if you believe that your patient’s health could be at risk if you have to wait 15 days until a decision is made. In case of an expedited appeal, a decision must be made within 48 hours or less of receiving your request for an appeal.

If any documentation submitted states that a waiting period of 15 days impacts the health of your patient or the patient would be in danger, we will automatically grant a fast appeal.

 In your written request for an appeal, you must include: patients name, address, identification number, the reason for the appeal, and any evidence you wish to attach. You can submit medical reports, supporting letters, or other information that contributes to your case. You can submit the information by mail or via fax.

An appeal must be filed in writing by sending a letter with your allegations and contract number to the following address or fax:

CerpassRx

5904 Stone Creek Drive, Ste. 120

The Colony, TX 75056

Fax: (469) 592-6460

 You may file a request for an external review for your patient. You will receive more information about how to request an independent review if your appeal is denied by the plan, or you may contact us.

 For most types of claims, you have the right to request an independent external review of our decision no later than 120 days from the date of notification of the adverse outcome of your appeal. Contact CerpassRx with any questions you may have about your patients right to an external review.

Please contact CerpassRx Member Services at 844-622-1797 with any questions.