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1 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) BACKGROUND SECTION 1 Intrductin Sectin 1.1 What t d if yu have a prblem r cncern This chapter explains tw types f prcesses fr handling prblems and cncerns: Fr sme types f prblems, yu need t use the prcess fr cverage decisins and making appeals. Fr ther types f prblems yu need t use the prcess fr making cmplaints. Bth f these prcesses have been apprved by Medicare. T ensure fairness and prmpt handling f yur prblems, each prcess has a set f rules, prcedures, and deadlines that must be fllwed by us and by yu. Which ne d yu use? That depends n the type f prblem yu are having. The guide in Sectin 3 will help yu identify the right prcess t use. Sectin 1.2 What abut the legal terms? There are technical legal terms fr sme f the rules, prcedures, and types f deadlines explained in this chapter. Many f these terms are unfamiliar t mst peple and can be hard t understand. T keep things simple, this chapter explains the legal rules and prcedures using mre cmmn wrds in place f certain legal terms. Fr example, this chapter generally says making a cmplaint rather than filing a grievance, cverage decisin rather than rganizatin determinatin r cverage determinatin, and Independent Review Organizatin instead f Independent Review Entity. It als uses abbreviatins as little as pssible. Hwever, it can be helpful and smetimes quite imprtant fr yu t knw the crrect legal terms fr the situatin yu are in. Knwing which terms t use will help yu cmmunicate mre clearly and accurately when yu are dealing with yur prblem and get the right help r infrmatin fr yur situatin. T help yu knw which terms t use, we include legal terms when we give the details fr handling specific types f situatins. SECTION 2 Yu can get help frm gvernment rganizatins that are nt cnnected with us Sectin 2.1 Where t get mre infrmatin and persnalized assistance Smetimes it can be cnfusing t start r fllw thrugh the prcess fr dealing with a prblem. This can be especially true if yu d nt feel well r have limited energy. Other times, yu may nt have the knwledge yu need t take the next step. Perhaps bth are true fr yu. Get help frm an independent gvernment rganizatin We are always available t help yu. But in sme situatins yu may als want help r guidance frm smene wh is nt cnnected with us. Yu can always cntact yur State Health Insurance Assistance Prgram (SHIP). This gvernment prgram has trained cunselrs in every state. The prgram is nt

2 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) cnnected with ur plan r with any insurance cmpany r health plan. The cunselrs at this prgram can help yu understand which prcess yu shuld use t handle a prblem yu are having. They can als answer yur questins, give yu mre infrmatin, and ffer guidance n what t d. The services f SHIP cunselrs are free. Yu will find phne numbers in Chapter 2, Sectin 3 f the EOC. Yu can als get help and infrmatin frm Medicare Fr mre infrmatin and help in handling a prblem, yu can als cntact Medicare. Here are tw ways t get infrmatin directly frm Medicare: Yu can call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Yu can visit the Medicare website ( SECTION 3 T deal with yur prblem, which prcess shuld yu use? Sectin 3.1 Shuld yu use the prcess fr cverage decisins and appeals? Or shuld yu use the prcess fr making cmplaints? If yu have a prblem r cncern and yu want t d smething abut it, yu dn t need t read this whle chapter. Yu just need t find and read the parts f this chapter that apply t yur situatin. The guide that fllws will help. T figure ut which part f this chapter tells what t d fr yur prblem r cncern. START HERE Is yur prblem r cncern abut yur benefits and cverage? (This includes prblems abut whether particular medical care is cvered r nt, the way in which it is cvered, and prblems related t payment fr medical care. YES q G n t the next sectin f this chapter, Sectin 4: A Guide t the basics f cverage decisins and making appeals. NO q Skip ahead t Sectin 10 at the end f this chapter: Hw t make a cmplaint abut quality f care, waiting times, custmer service r ther cncerns.

3 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) COVERAGE DECISIONS AND APPEALS SECTION 4 A guide t the basics f cverage decisins and appeals Sectin 4.1 Asking fr cverage decisins and making appeals: the big picture The prcess fr cverage decisins and making appeals deals with prblems related t yur benefits and cverage fr medical services, including prblems related t payment. This is the prcess yu use fr issues such as whether smething is cvered r nt and the way in which smething is cvered. Asking fr cverage decisins A cverage decisin is a decisin we make abut yur benefits and cverage r abut the amunt we will pay fr yur medical services. We and/r yur dctr make a cverage decisin fr yu whenever yu g t a dctr fr medical care. Yu can als cntact the plan and ask fr a cverage decisin. Fr example, if yu want t knw if we will cver a medical service befre yu receive it, yu can ask us t make a cverage decisin fr yu. We are making a cverage decisin fr yu whenever we decide what is cvered fr yu and hw much we pay. In sme cases we might decide a service is nt cvered r is n lnger cvered by Medicare fr yu. If yu disagree with this cverage decisin, yu can make an appeal. Making an appeal If we make a cverage decisin and yu are nt satisfied with this decisin, yu can appeal the decisin. An appeal is a frmal way f asking us t review and change a cverage decisin we have made. When yu make an appeal, we review the cverage decisin we have made t check t see if we were fllwing all f the rules prperly. When we have cmpleted the review we give yu ur decisin. If we say n t all r part f yur Level 1 Appeal, yu can g n t a Level 2 Appeal. The Level 2 Appeal is cnducted by an independent rganizatin that is nt cnnected t ur plan. If yu are nt satisfied with the decisin at the Level 2 Appeal, yu may be able t cntinue thrugh several mre levels f appeal. Sectin 4.2 Hw t get help when yu are asking fr a cverage decisin r making an appeal Wuld yu like sme help? Here are resurces yu may wish t use if yu decide t ask fr any kind f cverage decisin r appeal a decisin: Yu can call us at Member Services (phne numbers are n the cver). T get free help frm an independent rganizatin that is nt cnnected with ur plan, cntact yur State Health Insurance Assistance Prgram (see Sectin 2 f this chapter). Yur dctr r ther prvider can make a request fr yu. Yur dctr r ther prvider can request a cverage decisin r a Level 1 Appeal n yur behalf. T request any appeal after Level 1, yur dctr r ther prvider must be appinted as yur representative.

4 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Yu can ask smene t act n yur behalf. If yu want t, yu can name anther persn t act fr yu as yur representative t ask fr a cverage decisin r make an appeal. There may be smene wh is already legally authrized t act as yur representative under State law. If yu want a friend, relative, yur dctr r ther prvider, r ther persn t be yur representative, call Member Services and ask fr the frm t give that persn permissin t act n yur behalf. The frm must be signed by yu and by the persn wh yu wuld like t act n yur behalf. Yu must give ur plan a cpy f the signed frm. Yu als have the right t hire a lawyer t act fr yu. Yu may cntact yur wn lawyer, r get the name f a lawyer frm yur lcal bar assciatin r ther referral service. There are als grups that will give yu free legal services if yu qualify. Hwever, yu are nt required t hire a lawyer t ask fr any kind f cverage decisin r appeal a decisin. Sectin 4.3 Which sectin f this chapter gives the details fr yur situatin? There are three different types f situatins that invlve cverage decisins and appeals. Since each situatin has different rules and deadlines, we give the details fr each ne in a separate sectin: Sectin 5 f this chapter Sectin 7 f this chapter Sectin 8 f this chapter q q q Hw t ask us t keep Yur medical care: Hw t ask fr a cverage decisin r make an appeal Hw t ask us t cver a lnger hspital stay if yu think the dctr is discharging yu t sn cvering certain medical services if yu think yur cverage is ending t sn (Applies t these services nly: hme health care, skilled nursing facility care, and Cmprehensive Outpatient Rehabilitatin Facility (CORF) services) If yu re still nt sure which sectin yu shuld be using, please call Member Services (phne numbers are n the frnt cver f the EOC). Yu can als get help r infrmatin frm gvernment rganizatins such as yur State Health Insurance Assistance Prgram (Chapter 2, Sectin 3, f the EOC has the phne numbers fr this prgram). SECTION 5 Yur medical care: Hw t ask fr a cverage decisin r make an appeal? Have yu read Sectin 4 f this chapter (A guide t the basics f cverage decisins and appeals)? If nt, yu may want t read it befre yu start this sectin.

5 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Sectin 5.1 This sectin tells what t d if yu have prblems getting cverage fr medical care r if yu want us t pay yu back fr ur share f the cst f yur care This sectin is abut yur benefits fr medical care and services. These are the benefits described in Chapter 4 f the EOC: Medical Benefits Chart (what is cvered and what yu pay). T keep things simple, we generally refer t medical care cverage r medical care in the rest f this sectin, instead f repeating medical care r treatment r services every time. This sectin tells what yu can d if yu are in any f the five fllwing situatins: 1. Yu are nt getting certain medical care yu want, and yu believe that this care is cvered by ur plan. 2. Our plan will nt apprve the medical care yur dctr r ther medical prvider wants t give yu, and yu believe that this care is cvered by the plan. 3. Yu have received medical care r services that yu believe shuld be cvered by the plan, but we have said we will nt pay fr this care. 4. Yu have received and paid fr medical care r services that yu believe shuld be cvered by the plan, and yu want t ask ur plan t reimburse yu fr this care. 5. Yu are being tld that cverage fr certain medical care yu have been getting will be reduced r stpped, and yu believe that reducing r stpping this care culd harm yur health. NOTE: If the cverage that will be stpped is fr hspital care, hme health care, skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility (CORF) services, yu need t read a separate sectin f this chapter because special rules apply t these types f care. Here s what t read in thse situatins: Chapter 9, Sectin 7: Hw t ask fr a lnger hspital stay if yu think yu are being asked t leave the hspital t sn. Chapter 9, Sectin 8: Hw t ask ur plan t keep cvering certain medical services if yu think yur cverage is ending t sn. This sectin is abut three services nly: hme health care, skilled nursing facility care, and Cmprehensive Outpatient Rehabilitatin Facility (CORF) services. Fr all ther situatins that invlve being tld that medical care yu have been getting will be stpped, use this sectin (Sectin 5) as yur guide fr what t d.

6 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Which f these situatins are yu in? D yu want t find ut whether ur plan will cver the medical care r services yu want? Has ur plan already tld yu that we will nt cver r pay fr a medical service in the way that yu want it t be cvered r paid fr? q q q D yu want t ask ur plan t pay yu back fr medical care r services yu have already received and paid fr? Yu need t ask ur plan t make a cverage decisin fr yu. G n the next sectin f this chapter, Sectin 5.2. Yu can make an appeal. (This means yu are asking us t recnsider.) Skip ahead t Sectin 5.3 f this chapter Yu can send us the bill. Skip ahead t Sectin 5.5 f this chapter. Sectin 5.2 Step-by-step: Hw t ask fr a cverage decisin (hw t ask ur plan t authrize r prvide the medical care cverage yu want) When a cverage decisin invlves yur medical care, it is called an rganizatin determinatin. Step 1: Yu ask ur plan t make a cverage decisin n the medical care yu are requesting. If yur health requires a quick respnse, yu shuld ask us t make a fast decisin. A fast decisin is called an expedited decisin. Hw t request cverage fr the medical care yu want Start by calling, writing, r faxing ur plan t make yur request fr us t authrize r prvide cverage fr the medical care yu want. Yu, r yur dctr, r yur representative can d this. Fr the details n hw t cntact us, g t Chapter 2, Sectin 1.2 f the EOC and lk fr the sectin called, Hw t cntact ur plan when yu are asking fr a cverage decisin abut yur medical care. Generally we use the standard deadlines fr giving yu ur decisin When we give yu ur decisin, we will use the standard deadlines unless we have agreed t use the fast deadlines. A standard decisin means we will give yu an answer within 14 days after we receive yur request.

7 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Hwever, we can take up t 14 mre days if yu ask fr mre time, r if we need infrmatin (such as medical recrds) that may benefit yu. If we decide t take extra days t make the decisin, we will tell yu in writing. If yu believe we shuld nt take extra days, yu can file a fast cmplaint abut ur decisin t take extra days. When yu file a fast cmplaint, we will give yu an answer t yur cmplaint within 24 hurs. (The prcess fr making a cmplaint is different frm the prcess fr cverage decisins and appeals. Fr mre infrmatin abut the prcess fr making cmplaints, including fast cmplaints, see Sectin 10 f this chapter.) If yur health requires it, ask us t give yu a fast decisin A fast decisin means we will answer within 72 hurs. Hwever, we can take up t 14 mre days if we find that sme infrmatin is missing that may benefit yu, r if yu need time t get infrmatin t us fr the review. If we decide t take extra days, we will tell yu in writing. If yu believe we shuld nt take extra days, yu can file a fast cmplaint abut ur decisin t take extra days. (Fr mre infrmatin abut the prcess fr making cmplaints, including fast cmplaints, see Sectin 10 f this chapter.) We will call yu as sn as we make the decisin. T get a fast decisin, yu must meet tw requirements: Yu can get a fast decisin nly if yu are asking fr cverage fr medical care yu have nt yet received. (Yu cannt get a fast decisin if yur request is abut payment fr medical care yu have already received.) Yu can get a fast decisin nly if using the standard deadlines culd cause serius harm t yur health r hurt yur ability t functin. If yur dctr tells us that yur health requires a fast decisin, we will autmatically agree t give yu a fast decisin. If yu ask fr a fast decisin n yur wn, withut yur dctr s supprt, ur plan will decide whether yur health requires that we give yu a fast decisin. If we decide that yur medical cnditin des nt meet the requirements fr a fast decisin, we will send yu a letter that says s (and we will use the standard deadlines instead). This letter will tell yu that if yur dctr asks fr the fast decisin, we will autmatically give a fast decisin. The letter will als tell hw yu can file a fast cmplaint abut ur decisin t give yu a standard decisin instead f the fast decisin yu requested. (Fr mre infrmatin abut the prcess fr making cmplaints, including fast cmplaints, see Sectin 10 f this chapter.) Step 2: Our plan cnsiders yur request fr medical care cverage and we give yu ur answer. Deadlines fr a fast cverage decisin Generally, fr a fast decisin, we will give yu ur answer within 72 hurs.

8 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) As explained abve, we can take up t 14 mre days under certain circumstances. If we decide t take extra days t make the decisin, we will tell yu in writing. If we take extra days, it is called an extended time perid. If we d nt give yu ur answer within 72 hurs (r if there is an extended time perid, by the end f that perid), yu have the right t appeal. Sectin 5.3 belw tells hw t make an appeal. If ur answer is yes t part r all f what yu requested, we must authrize r prvide the medical care cverage we have agreed t prvide within 72 hurs after we received yur request. If we extended the time needed t make ur decisin, we will prvide the cverage by the end f that extended perid. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. Deadlines fr a standard cverage decisin Generally, fr a standard decisin, we will give yu ur answer within 14 days f receiving yur request. We can take up t 14 mre days ( an extended time perid ) under certain circumstances. If we decide t take extra days t make the decisin, we will tell yu in writing. If we d nt give yu ur answer within 14 days (r if there is an extended time perid, by the end f that perid), yu have the right t appeal. Sectin 5.3 belw tells hw t make an appeal. If ur answer is yes t part r all f what yu requested, we must authrize r prvide the cverage we have agreed t prvide within 14 days after we received yur request. If we extended the time needed t make ur decisin, we will prvide the cverage by the end f that extended perid. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. Step 3: If we say n t yur request fr cverage fr medical care, yu decide if yu want t make an appeal. If ur plan says n, yu have the right t ask us t recnsider and perhaps change this decisin by making an appeal. Making an appeal means making anther try t get the medical care cverage yu want. If yu decide t make appeal, it means yu are ging n t Level 1 f the appeals prcess (see Sectin 5.3 belw). Sectin 5.3 Step-by-step: Hw t make a Level 1 Appeal (hw t ask fr a review f a medical care cverage decisin made by ur plan) When yu start the appeal prcess by making an appeal, it is called the first level f appeal r a Level 1 Appeal. An appeal t the plan abut a medical care cverage

9 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) decisin is called a plan recnsideratin. Step 1: Yu cntact ur plan and make yur appeal. If yur health requires a quick respnse, yu must ask fr a fast appeal. What t d T start yur appeal, yu (r yur dctr r yur representative) must cntact ur plan. Fr details n hw t reach us fr any purpse related t yur appeal, g t Chapter 2, Sectin 1.2 f the EOC lk fr sectin called, Hw t cntact ur plan when yu are making an appeal abut yur medical care. If yu are asking fr a standard appeal, make yur standard appeal in writing by submitting a signed request. If yu are asking fr a fast appeal, make yur appeal in writing r call us at the phne number shwn in Chapter 2, Sectin 1 f the EOC (Hw t cntact ur plan when yu are making an appeal abut yur medical care). Yu must make yur appeal request within 60 calendar days frm the date n the written ntice we sent t tell yu ur answer t yur request fr a cverage decisin. If yu miss this deadline and have a gd reasn fr missing it, we may give yu mre time t make yur appeal. Yu can ask fr a cpy f the infrmatin regarding yur medical decisin and add mre infrmatin t supprt yur appeal. Yu have the right t ask us fr a cpy f the infrmatin regarding yur appeal. We are allwed t charge a fee fr cpying and sending this infrmatin t yu. If yu wish, yu and yur dctr may give us additinal infrmatin t supprt yur appeal. If yur health requires it, ask fr a fast appeal (yu can make an ral request) A fast appeal is als called an expedited appeal. If yu are appealing a decisin ur plan made abut cverage fr care yu have nt yet received, yu and/r yur dctr will need t decide if yu need a fast appeal. The requirements and prcedures fr getting a fast appeal are the same as thse fr getting a fast decisin. T ask fr a fast appeal, fllw the instructins fr asking fr a fast decisin. (These instructins are given earlier in this Sectin.) If yur dctr tells us that yur health requires a fast appeal, we will give yu a fast appeal. Step 2: Our plan cnsiders yur appeal and we give yu ur answer. When ur plan is reviewing yur appeal, we take anther careful lk at all f the infrmatin abut yur request fr cverage f medical care. We check t see if we were fllwing all the rules when we said n t yur request. We will gather mre infrmatin if we need it. We may cntact yu r yur dctr t get mre infrmatin.

10 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Deadlines fr a fast appeal When we are using the fast deadlines, we must give yu ur answer within 72 hurs after we receive yur appeal. We will give yu ur answer sner if yur health requires us t d s. Hwever, if yu ask fr mre time, r if we need t gather mre infrmatin that may benefit yu, we can take up t 14 mre calendar days. If we decide t take extra days t make the decisin, we will tell yu in writing. If we d nt give yu an answer within 72 hurs (r by the end f the extended time perid if we tk extra days), we are required t autmatically send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent rganizatin. Later in this sectin, we tell yu abut this rganizatin and explain what happens at Level 2 f the appeals prcess. If ur answer is yes t part r all f what yu requested, we must authrize r prvide the cverage we have agreed t prvide within 72 hurs after we receive yur appeal. If ur answer is n t part r all f what yu requested, we will send yu a written denial ntice infrming yu that we have autmatically sent yur appeal t the Independent Review Organizatin fr a Level 2 Appeal. Deadlines fr a standard appeal If we are using the standard deadlines, we must give yu ur answer within 30 calendar days after we receive yur appeal if yur appeal is abut cverage fr services yu have nt yet received. We will give yu ur decisin sner if yur health cnditin requires us t. Hwever, if yu ask fr mre time, r if we need t gather mre infrmatin that may benefit yu, we can take up t 14 mre calendar days. If we d nt give yu an answer by the deadline abve (r by the end f the extended time perid if we tk extra days), we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent utside rganizatin. Later in this sectin, we tell abut this review rganizatin and explain what happens at Level 2 f the appeals prcess. If ur answer is yes t part r all f what yu requested, we must authrize r prvide the cverage we have agreed t prvide within 30 days after we receive yur appeal. If ur answer is n t part r all f what yu requested, we will send yu a written denial ntice infrming yu that we have autmatically sent yur appeal t the Independent Review Organizatin fr a Level 2 Appeal. Step 3: If ur plan says n t part r all f yur appeal, yur case will autmatically be sent n t the next level f the appeals prcess. T make sure we were fllwing all the rules when we said n t yur appeal, ur plan is required t send yur appeal t the Independent Review Organizatin. When we d this, it means that yur appeal is ging n t the next level f the appeals prcess, which is Level 2. Sectin 5.4 Step-by-step: Hw t make a Level 2 Appeal

11 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) If ur plan says n t yur Level 1 Appeal, yur case will autmatically be sent n t the next level f the appeals prcess. During the Level 2 Appeal, the Independent Review Organizatin reviews the decisin ur plan made when we said n t yur first appeal. This rganizatin decides whether the decisin we made shuld be changed. The frmal name fr the Independent Review Organizatin is the "Independent Review Entity." It is smetimes called the IRE. Step 1: The Independent Review Organizatin reviews yur appeal. The Independent Review Organizatin is an utside, independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with ur plan and it is nt a gvernment agency. This rganizatin is a cmpany chsen by Medicare t handle the jb f being the Independent Review Organizatin. Medicare versees its wrk. (Fr mre infrmatin abut this rganizatin, g t Chapter 2 f the EOC and lk fr Sectin 5.) We will send the infrmatin abut yur appeal t this rganizatin. This infrmatin is called yur case file. Yu have the right t ask us fr a cpy f yur case file. We are allwed t charge yu a fee fr cpying and sending this infrmatin t yu. Yu have a right t give the Independent Review Organizatin additinal infrmatin t supprt yur appeal. Reviewers at the Independent Review Organizatin will take a careful lk at all f the infrmatin related t yur appeal. If yu had a fast appeal at Level 1, yu will als have a fast appeal at Level 2 If yu had a fast appeal t ur plan at Level 1, yu will autmatically receive a fast appeal at Level 2. The review rganizatin must give yu an answer t yur Level 2 Appeal within 72 hurs f when it receives yur appeal. Hwever, if the Independent Review Organizatin needs t gather mre infrmatin that may benefit yu, it can take up t 14 mre calendar days. If yu had a standard appeal at Level 1, yu will als have a standard appeal at Level 2 If yu had a standard appeal t ur plan at Level 1, yu will autmatically receive a standard appeal at Level 2. The review rganizatin must give yu an answer t yur Level 2 Appeal within 30 calendar days f when it receives yur appeal. Hwever, if the Independent Review Organizatin needs t gather mre infrmatin that may benefit yu, it can take up t 14 mre calendar days. Step 2: The Independent Review Organizatin gives yu their answer. The Independent Review Organizatin will tell yu its decisin in writing and explain the reasns fr it.

12 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) If the review rganizatin says yes t part r all f what yu requested, we must authrize the medical care cverage within 72 hurs r prvide the service within 14 calendar days after we receive the decisin frm the review rganizatin. If this rganizatin says n t part r all f yur appeal, it means they agree with ur plan that yur request (r part f yur request) fr cverage fr medical care shuld nt be apprved. (This is called uphlding the decisin. It is als called turning dwn yur appeal. ) The ntice yu get frm the Independent Review Organizatin will tell yu in writing if yur case meets the requirements fr cntinuing with the appeals prcess. Fr example, t cntinue and make anther appeal at Level 3, the dllar value f the medical care cverage yu are requesting must meet a certain minimum. If the dllar value f the cverage yu are requesting is t lw, yu cannt make anther appeal, which means that the decisin at Level 2 is final. Step 3: If yur case meets the requirements, yu chse whether yu want t take yur appeal further. There are three additinal levels in the appeals prcess after Level 2 (fr a ttal f five levels f appeal). If yur Level 2 Appeal is turned dwn and yu meet the requirements t cntinue with the appeals prcess, yu must decide whether yu want t g n t Level 3 and make a third appeal. The details n hw t d this are in the written ntice yu gt after yur Level 2 Appeal. The Level 3 Appeal is handled by an administrative law judge. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. Sectin 5.5 What if yu are asking ur plan t pay yu fr ur share f a bill yu have received fr medical care? If yu want t ask ur plan fr payment fr medical care, start by reading Chapter 5 f the EOC: Asking the plan t pay its share f a bill yu have received fr medical services Chapter 5 f the EOC describes the situatins in which yu may need t ask fr reimbursement r t pay a bill yu have received frm a prvider. It als tells hw t send us the paperwrk that asks us fr payment. Asking fr reimbursement is asking fr a cverage decisin frm ur plan If yu send us the paperwrk that asks fr reimbursement, yu are asking us t make a cverage decisin (fr mre infrmatin abut cverage decisins, see Sectin 4.1 f this chapter). T make this cverage decisin, we will check t see if the medical care yu paid fr is a cvered service (see Chapter 4 f the EOC: Medical Benefits Chart (what is cvered and what yu pay)). We will als check t see if yu fllwed all the rules fr using yur cverage fr medical care (these rules are given in Chapter 3 f the EOC: Using the plan s cverage fr yur medical services). We will say yes r n t yur request If the medical care yu paid fr is cvered and yu fllwed all the rules, we will send yu the payment fr ur share f the cst f yur medical care within 60 calendar days after we receive yur request. Or, if yu haven t paid fr the services, we will send the payment directly t the prvider. When we send the payment, it s the same as saying yes t yur request fr a cverage decisin.)

13 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) If the medical care is nt cvered, r yu did nt fllw all the rules, we will nt send payment. Instead, we will send yu a letter that says we will nt pay fr the services and the reasns why. (When we turn dwn yur request fr payment, it s the same as saying n t yur request fr a cverage decisin.) What if yu ask fr payment and we say that we will nt pay? If yu d nt agree with ur decisin t turn yu dwn, yu can make an appeal. If yu make an appeal, it means yu are asking us t change the cverage decisin we made when we turned dwn yur request fr payment. T make this appeal, fllw the prcess fr appeals that we describe in part 5.3 f this sectin. G t this part fr step-by-step instructins. When yu are fllwing these instructins, please nte: If yu make an appeal fr reimbursement, we must give yu ur answer within 60 calendar days after we receive yur appeal. (If yu are asking us t pay yu back fr medical care yu have already received and paid fr yurself, yu are nt allwed t ask fr a fast appeal.) If the Independent Review Organizatin reverses ur decisin t deny payment, we must send the payment yu have requested t yu r t the prvider within 30 calendar days. If the answer t yur appeal is yes at any stage f the appeals prcess after Level 2, we must send the payment yu requested t yu r t the prvider within 60 calendar days. SECTION 6 Yur Part D prescriptin drugs: Hw t ask fr a cverage decisin r make an appeal Sectin has been mitted because Part D prescriptin drugs are nt cvered by this plan. SECTION 7 Hw t ask us t cver a lnger hspital stay if yu think the dctr is discharging yu t sn When yu are admitted t a hspital, yu have the right t get all f yur cvered hspital services that are necessary t diagnse and treat yur illness r injury. Fr mre infrmatin abut ur cverage fr yur hspital care, including any limitatins n this cverage, see Chapter 4 f the EOC: Medical Benefits Chart (what is cvered and what yu pay). During yur hspital stay, yur dctr and the hspital staff will be wrking with yu t prepare fr the day when yu will leave the hspital. They will als help arrange fr care yu may need after yu leave. The day yu leave the hspital is called yur discharge date. Our plan s cverage f yur hspital stay ends n this date. When yur discharge date has been decided, yur dctr r the hspital staff will let yu knw. If yu think yu are being asked t leave the hspital t sn, yu can ask fr a lnger hspital stay and yur request will be cnsidered. This sectin tells yu hw t ask. Sectin 7.1 During yur hspital stay, yu will get a written ntice frm Medicare that tells abut yur rights

14 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) During yur hspital stay, yu will be given a written ntice called An Imprtant Message frm Medicare abut Yur Rights. Everyne with Medicare gets a cpy f this ntice whenever they are admitted t a hspital. Smene at the hspital is suppsed t give it t yu within tw days after yu are admitted. 1. Read this ntice carefully and ask questins if yu dn t understand it. It tells yu abut yur rights as a hspital patient, including: Yur right t receive Medicare-cvered services during and after yur hspital stay, as rdered by yur dctr. This includes the right t knw what these services are, wh will pay fr them, and where yu can get them. Yur right t be invlved in any decisins abut yur hspital stay, and knw wh will pay fr it. Where t reprt any cncerns yu have abut quality f yur hspital care. What t d if yu think yu are being discharged frm the hspital t sn. The written ntice frm Medicare tells yu hw yu can make an appeal. Making an appeal is a frmal, legal way t ask fr a delay in yur discharge date s that yur hspital care will be cvered fr a lnger time. (Sectin 7.2 belw tells hw t make this appeal.) 2. Yu must sign the written ntice t shw that yu received it and understand yur rights. Yu r smene wh is acting n yur behalf must sign the ntice. (Sectin 4 f this chapter tells hw yu can give written permissin t smene else t act as yur representative.) Signing the ntice shws nly that yu have received the infrmatin abut yur rights. The ntice des nt give yur discharge date (yur dctr r hspital staff will tell yu yur discharge date). Signing the ntice des nt mean yu are agreeing n a discharge date. 3. Keep yur cpy f the signed ntice s yu will have the infrmatin abut making an appeal (r reprting a cncern abut quality f care) handy if yu need it. If yu sign the ntice mre than 2 days befre the day yu leave the hspital, yu will get anther cpy befre yu are scheduled t be discharged. T lk at a cpy f this ntice in advance, yu can call Member Services r MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Yu can als see it nline at Sectin 7.2 Step-by-step: Hw t make a Level 1 Appeal t change yur hspital discharge date If yu want t ask fr yur hspital services t be cvered by ur plan fr a lnger time, yu will need t use the appeals prcess t make this request. Befre yu start, understand what yu need t d and what the deadlines are. Fllw the prcess. Each step in the first tw levels f the appeals prcess is explained belw. Meet the deadlines. The deadlines are imprtant. Be sure that yu understand and fllw the deadlines that apply t things yu must d.

15 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Ask fr help if yu need it. If yu have questins r need help at any time, please call Member Services (phne numbers are n the frnt cver f the EOC). Or call yur State Health Insurance Assistance Prgram, a gvernment rganizatin that prvides persnalized assistance (see Sectin 2 f this chapter). During a Level 1 Appeal, the Quality Imprvement Organizatin reviews yur appeal. It checks t see if yur planned discharge date is medically apprpriate fr yu. When yu start the appeal prcess by making an appeal, it is called the first level f appeal r a Level 1 Appeal. Step 1: Cntact the Quality Imprvement Organizatin in yur state and ask fr a fast review f yur hspital discharge. Yu must act quickly. A fast review is als called an immediate review r an expedited review. What is the Quality Imprvement Organizatin? This rganizatin is a grup f dctrs and ther health care prfessinals wh are paid by the Federal gvernment. These experts are nt part f ur plan. This rganizatin is paid by Medicare t check n and help imprve the quality f care fr peple with Medicare. This includes reviewing hspital discharge dates fr peple with Medicare. Hw can yu cntact this rganizatin? Act quickly: The written ntice yu received (An Imprtant Message frm Medicare) tells yu hw t reach this rganizatin. (Or find the name, address, and phne number f the Quality Imprvement Organizatin fr yur state in Chapter 2, Sectin 4, f the EOC.) T make yur appeal, yu must cntact the Quality Imprvement Organizatin befre yu leave the hspital and n later than yur planned discharge date. (Yur planned discharge date is the date that has been set fr yu t leave the hspital.) If yu meet this deadline, yu are allwed t stay in the hspital after yur discharge date withut paying fr it while yu wait t get the decisin n yur appeal frm the Quality Imprvement Organizatin. If yu d nt meet this deadline, and yu decide t stay in the hspital after yur planned discharge date, yu may have t pay all f the csts fr hspital care yu receive after yur planned discharge date. If yu miss the deadline fr cntacting the Quality Imprvement Organizatin abut yur appeal, yu can make yur appeal directly t ur plan instead. Fr details abut this ther way t make yur appeal, see Sectin 7.4. Ask fr a fast review :

16 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Yu must ask the Quality Imprvement Organizatin fr a fast review f yur discharge. Asking fr a fast review means yu are asking fr the rganizatin t use the fast deadlines fr an appeal instead f using the standard deadlines. A fast review is als called an immediate review r an expedited review. Step 2: The Quality Imprvement Organizatin cnducts an independent review f yur case. What happens during this review? Health prfessinals at the Quality Imprvement Organizatin (we will call them the reviewers fr shrt) will ask yu (r yur representative) why yu believe cverage fr the services shuld cntinue. Yu dn t have t prepare anything in writing, but yu may d s if yu wish. The reviewers will als lk at yur medical infrmatin, talk with yur dctr, and review infrmatin that the hspital and ur plan has given t them. By nn f the day after the reviewers infrmed ur plan f yur appeal, yu will als get a written ntice that gives yur planned discharge date and explains the reasns why yur dctr, the hspital, and ur plan think it is right (medically apprpriate) fr yu t be discharged n that date. This written explanatin is called the Detailed Ntice f Discharge. Yu can get a sample f this ntice by calling Member Services r MEDICARE ( , 24 hurs a day, 7 days a week. TTY users shuld call ) Or yu can get see a sample ntice nline at Step 3: Within ne full day after it has all the needed infrmatin, the Quality Imprvement Organizatin will give yu its answer t yur appeal. What happens if the answer is yes? If the review rganizatin says yes t yur appeal, ur plan must keep prviding yur cvered hspital services fr as lng as these services are medically necessary. Yu will have t keep paying yur share f the csts (such as deductibles r cpayments, if these apply). In additin, there may be limitatins n yur cvered hspital services. (See Chapter 4 f the EOC). What happens if the answer is n? If the review rganizatin says n t yur appeal, they are saying that yur planned discharge date is medically apprpriate. (Saying n t yur appeal is als called turning dwn yur appeal.) If this happens, ur plan s cverage fr yur hspital services will end at nn n the day after the Quality Imprvement Organizatin gives yu its answer t yur appeal. If the review rganizatin says n t yur appeal and yu decide t stay in the hspital, then yu may have t pay the full cst f hspital care yu receive after nn n the day after the Quality Imprvement Organizatin gives yu its answer t yur appeal.

17 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Step 4: If the answer t yur Level 1 Appeal is n, yu decide if yu want t make anther appeal. If the Quality Imprvement Organizatin has turned dwn yur appeal, and yu stay in the hspital after yur planned discharge date, then yu can make anther appeal. Making anther appeal means yu are ging n t Level 2 f the appeals prcess. Sectin 7.3 Step-by-step: Hw t make a Level 2 Appeal t change yur hspital discharge date If the Quality Imprvement Organizatin has turned dwn yur appeal, and yu stay in the hspital after yur planned discharge date, then yu can make a Level 2 Appeal. During a Level 2 Appeal, yu ask the Quality Imprvement Organizatin t take anther lk at the decisin they made n yur first appeal. Here are the steps fr Level 2 f the appeal prcess: Step 1: Yu cntact the Quality Imprvement Organizatin again and ask fr anther review. Yu must ask fr this review within 60 calendar days after the day when the Quality Imprvement Organizatin said n t yur Level 1 Appeal. Yu can ask fr this review nly if yu stayed in the hspital after the date that yur cverage fr the care ended. Step 2: The Quality Imprvement Organizatin des a secnd review f yur situatin. Reviewers at the Quality Imprvement Organizatin will take anther careful lk at all f the infrmatin related t yur appeal. Step 3: Within 14 calendar days, the Quality Imprvement Organizatin reviewers will decide n yur appeal and tell yu their decisin. If the review rganizatin says yes: Our plan must reimburse yu fr ur share f the csts f hspital care yu have received since nn n the day after the date yur first appeal was turned dwn by the Quality Imprvement Organizatin. Our plan must cntinue prviding cverage fr yur hspital care fr as lng as it is medically necessary. Yu must cntinue t pay yur share f the csts and cverage limitatins may apply. If the review rganizatin says n: It means they agree with the decisin they made t yur Level 1 Appeal and will nt change it. This is called uphlding the decisin. It is als called turning dwn yur appeal. The ntice yu get will tell yu in writing what yu can d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t the next level f appeal, which is handled by a judge. Step 4: If the answer is n, yu will need t decide whether yu want t take yur appeal further by ging n t Level 3.

18 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) There are three additinal levels in the appeals prcess after Level 2 (fr a ttal f five levels f appeal). If the review rganizatin turns dwn yur Level 2 Appeal, yu can chse whether t accept that decisin r whether t g n t Level 3 and make anther appeal. At Level 3, yur appeal is reviewed by a judge. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. Sectin 7.4 What if yu miss the deadline fr making yur Level 1 Appeal? Yu can appeal t ur plan instead As explained abve in Sectin 7.2, yu must act quickly t cntact the Quality Imprvement Organizatin t start yur first appeal f yur hspital discharge. ( Quickly means befre yu leave the hspital and n later than yur planned discharge date). If yu miss the deadline fr cntacting this rganizatin, there is anther way t make yur appeal. If yu use this ther way f making yur appeal, the first tw levels f appeal are different. Step-by-Step: Hw t make a Level 1 Alternate Appeal If yu miss the deadline fr cntacting the Quality Imprvement Organizatin, yu can make an appeal t ur plan, asking fr a fast review. A fast review is an appeal that uses the fast deadlines instead f the standard deadlines. A fast review (r fast appeal ) is als called an expedited review (r expedited appeal ). Step 1: Cntact ur plan and ask fr a fast review. Fr details n hw t cntact ur plan, g t Chapter 2 f the EOC, Sectin 1.2 and lk fr the sectin called, Hw t cntact ur plan when yu are making an appeal abut yur medical care. Be sure t ask fr a fast review. This means yu are asking us t give yu an answer using the fast deadlines rather than the standard deadlines. Step 2: Our plan des a fast review f yur planned discharge date, checking t see if it was medically apprpriate. During this review, ur plan takes a lk at all f the infrmatin abut yur hspital stay. We check t see if yur planned discharge date was medically apprpriate. We will check t see if the decisin abut when yu shuld leave the hspital was fair and fllwed all the rules. In this situatin, we will use the fast deadlines rather than the standard deadlines fr giving yu the answer t this review. Step 3: Our plan gives yu ur decisin within 72 hurs after yu ask fr a fast review ( fast appeal ). If ur plan says yes t yur fast appeal, it means we have agreed with yu that yu still need t be in the hspital after the discharge date, will t keep prviding yur cvered services fr as lng as it is medically necessary. It als means that we have agreed t reimburse yu fr ur share f the csts

19 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) f care yu have received since the date when we said yur cverage wuld end. (Yu must pay yur share f the csts and there may be cverage limitatins that apply.) If ur plan says n t yur fast appeal, we are saying that yur planned discharge date was medically apprpriate. Our cverage fr yur hspital services ends as f the day we said cverage wuld end. If yu stayed in the hspital after yur planned discharge date, then yu may have t pay the full cst f hspital care yu received after the planned discharge date. Step 4: If ur plan says n t yur fast appeal, yur case will autmatically be sent n t the next level f the appeals prcess. T make sure we were fllwing all the rules when we said n t yur fast appeal, ur plan is required t send yur appeal t the Independent Review Organizatin. When we d this, it means that yu are autmatically ging n t Level 2 f the appeals prcess. Step-by-Step: Hw t make a Level 2 Alternate Appeal If ur plan says n t yur Level 1 Appeal, yur case will autmatically be sent n t the next level f the appeals prcess. During the Level 2 Appeal, the Independent Review Organizatin reviews the decisin ur plan made when we said n t yur fast appeal. This rganizatin decides whether the decisin we made shuld be changed. The frmal name fr the Independent Review Organizatin is the Independent Review Entity. It is smetimes called the IRE. Step 1: We will autmatically frward yur case t the Independent Review Organizatin. We are required t send the infrmatin fr yur Level 2 Appeal t the Independent Review Organizatin within 24 hurs f when we tell yu that we are saying n t yur first appeal. (If yu think we are nt meeting this deadline r ther deadlines, yu can make a cmplaint. The cmplaint prcess is different frm the appeal prcess. Sectin 10 f this chapter tells hw t make a cmplaint.) Step 2: The Independent Review Organizatin des a fast review f yur appeal. The reviewers give yu an answer within 72 hurs. The Independent Review Organizatin is an utside, independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with ur plan and it is nt a gvernment agency. This rganizatin is a cmpany chsen by Medicare t handle the jb f being the Independent Review Organizatin. Medicare versees its wrk. (Fr mre infrmatin abut this rganizatin, g t Chapter 2 f the EOC and lk fr Sectin 5.) Reviewers at the Independent Review Organizatin will take a careful lk at all f the infrmatin related t yur appeal f yur hspital discharge. If this rganizatin says yes t yur appeal, then ur plan must reimburse yu (pay yu back) fr ur share f the csts f hspital care yu have received since the date f yur planned discharge. We must als cntinue the plan s cverage f yur hspital services fr as lng as it is medically necessary. Yu must cntinue t pay yur share f the csts. If there are cverage limitatins, these culd limit hw much we wuld reimburse r hw lng we wuld cntinue t cver yur services.

20 2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) If this rganizatin says n t yur appeal, it means they agree with ur plan that yur planned hspital discharge date was medically apprpriate. (This is called uphlding the decisin. It is als called turning dwn yur appeal. ) The ntice yu get frm the Independent Review Organizatin will tell yu in writing what yu can d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t a Level 3 Appeal, which is handled by a judge. Step 3: If the Independent Review Organizatin turns dwn yur appeal, yu chse whether yu want t take yur appeal further. There are three additinal levels in the appeals prcess after Level 2 (fr a ttal f five levels f appeal). If reviewers say n t yur Level 2 Appeal, yu decide whether t accept their decisin r g n t Level 3 and make a third appeal. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. SECTION 8 Hw t ask us t keep cvering certain medical services if yu think yur cverage is ending t sn Sectin 8.1 This sectin is abut three services nly: Hme health care, skilled nursing facility care, and Cmprehensive Outpatient Rehabilitatin Facility (CORF) services This sectin is abut the fllwing types f care nly: Hme health care services yu are getting. Skilled nursing care yu are getting as a patient in a skilled nursing facility. (T learn abut requirements fr being cnsidered a skilled nursing facility, Chapter 12 f the EOC, Definitins f imprtant wrds.) Rehabilitatin care yu are getting as an utpatient at a Medicare-apprved Cmprehensive Outpatient Rehabilitatin Facility (CORF) services. Usually, this means yu are getting treatment fr an illness r accident, r yu are recvering frm a majr peratin. (Fr mre abut this type f facility, see Chapter 12 f the EOC, Definitins f imprtant wrds.) When yu are getting any f these types f care, yu have the right t keep getting yur cvered services fr that type f care fr as lng as the care is needed t diagnse and treat yur illness r injury. Fr mre infrmatin n yur cvered services, including yur share f the cst and any limitatins t cverage that may apply, see Chapter 4 f the EOC: Medical Benefits Chart (what is cvered and what yu pay). When ur plan decides it is time t stp cvering any f the three types f care fr yu, we are required t tell yu in advance. When yur cverage fr that care ends, ur plan will stp paying its share f the cst fr yur care. If yu think we are ending the cverage f yur care t sn, yu can appeal ur decisin. This sectin tells yu hw t ask.