Appeals & Grievances

An organization determination is a decision we make about your benefits and coverage or about what we will pay for Medical Services.

If Eon Health denies all or part of a request for a service or payment of a service, you can ask for an appeal. A request for an appeal may be made by phone or in writing and typically must be filed within sixty calendar days from the date of the notice of the denial (organization determination). More time may be granted depending on circumstances. When you make an appeal, Eon Health will review your unfavorable organization determination. The first level of the appeal process for medical services (Part C) is called Reconsideration.

There are five levels of appeals. If the Reconsideration decision is not entirely in the member’s favor, Eon Health will forward the case to an Independent Review Entity (IRE). There are other levels of appeal that may be available after the IRE review.

As an Eon Health member, you, your appointed representative, or your prescribing physician may file for an appeal.

You may use the following form to request a medical (Part C) appeal:

Medical (Part C) Appeal Request Form

• You can call us at:

1-877-364-4566 (TTY: 711)

From October 1 – March 31, seven days a week, from 8 a.m – 8 p.m and April 1 – September 30, Monday through Friday, from 8 a.m – 8 p.m (you may leave a voicemail Saturday, Sunday and Federal Holidays). Calls to this number are free.

• Send a fax to:

1-855-231-8778

• Mail your request to:

Eon Health
Attn: Appeals & Grievances
3601 SW 160th Avenue, Suite 450
Miramar, FL 33027

If you are unsatisfied with the outcome of a coverage determination request, you can ask for an appeal. An appeal may be made by phone or in writing and the request must be filed within sixty calendar days from the date of the notice of denial (Coverage Determination). More time may be granted depending on circumstances. When you make an appeal, Eon Health will review your unfavorable coverage determination. The first level of the appeal process for prescription drug (Part D) is called Redetermination.

There are five levels of appeals. If the Redetermination decision is not entirely in the member’s favor, you will be notified in writing and you may request a review by the Independent Review Entity (IRE). There are other levels of appeal that may be available after the IRE review.

As an Eon Health member, you, your appointed representative, or your prescribing physician may file for an appeal of a coverage determination.

To file a redetermination, you may use the Redetermination Request Form

• You can call us at:

1-844-374-7377 (TTY: 1-800-716-3231)

From October 1 – March 31, seven days a week, from 8 a.m – 8 p.m and April 1 – September 30, Monday through Friday, from 8 a.m – 8 p.m (you may leave a voicemail Saturday, Sunday and Federal Holidays). Calls to this number are free.

• Send a fax to:

1-877-251-5896

• Mail your request to:

Express Scripts
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571

Eon Health tracks and maintains records about the receipt and handling of grievances, appeals, and exceptions. We will also disclose grievances, appeals, and exceptions data to you upon request. Eon Health can also provide an aggregate number of grievances, appeals, and exceptions filed with our plans. To obtain this data, please call Eon Health at the following toll-free number:

1-877-364-4566 (TTY: 711)

From October 1 – March 31, seven days a week, from 8 a.m – 8 p.m and April 1 – September 30, Monday through Friday, from 8 a.m – 8 p.m (you may leave a voicemail Saturday, Sunday and Federal Holidays)

Members may name a relative, friend, advocate, or someone else to act on his or her behalf. This process is called Appointing a Representative. Other persons may already be authorized under state law to act on a member’s behalf. In order to appoint another individual to act on a member’s behalf, both the member and the designated individual must sign and date a statement that gives this person legal permission to act as an Appointed Representative.

To appoint a representative, you may use this form: Appointment of Representative Form

After completing the form, please mail it to the following address:

Eon Health
Attn: Appeals & Grievances
3601 SW 160th Avenue, Suite 450
Miramar, FL 33027

For questions regarding the process or status of a coverage determination, grievance, organization determination, redetermination, or reconsideration request, you or your appointed representative should call Eon Health at the following toll-free number:

1-877-364-4566 (TTY: 711)

From October 1 – March 31, seven days a week, from 8 a.m – 8 p.m and April 1 – September 30, Monday through Friday, from 8 a.m – 8 p.m (you may leave a voicemail Saturday, Sunday and Federal Holidays). Calls to this number are free.

In accordance with the CMS Managed Care Manual, Chapter 13, Section 60.1.1, Non-Contract Providers are, "permitted to file a standard appeal for a denied claim only if the non-contract provider completes a waiver of liability statement, which providers that the non-contract provider will not bill the enrollee regardless of the outcome of the appeal".

If Eon Helth does not receive this required documentation by the end of the post-service appeal time frame (60 calendar days, plus an additional 14 days extension), the case will be dismissed, as per CMS guidance.