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What is the difference between a grievance and an appeal? A grievance is any complaint or dispute other than one involving an Organization Determination. Examples of issues that involve a complaint that will be resolved through the Grievance rather than the Appeal process are: Waiting times in participating provider offices; rudeness or unresponsiveness of Customer Service Staff. An appeal is any of the procedures that deal with the review of adverse organization determinations on the health care services a Member is entitled to receive or any amounts that the Member must pay for a covered service. These procedures include reconsideration by FamilyCare Health Plans, and, if necessary, an Independent Review Entity, hearings before Administrative Law Judges (of the Social Security Administration), review by the Medicare Appeals Council (MAC), and judicial review. The following sections outline the procedures you should follow if you want to file a grievance or appeal. GENERAL INFORMATION ON MEDICARE APPEAL PROCEDURES As a Member of a FamilyCare Health Plans, you have the right to appeal any decision about our payment for, or failure to arrange or continue to arrange for, what you believe are Covered Services (including non-Medicare covered Benefits) under a FamilyCare Health Plans Plan. Coverage decisions that are commonly appealed include decisions with respect to:
If your complaint does not involve one of these coverage decisions, you should use the FamilyCare Health Plans Grievance Procedure (discussed below). If you have a question about what type of complaint process to use, please call the FamilyCare Health Plans Customer Service Department. HOW TO FILE AN APPEAL OR GRIEVANCE Outside the local area: 1-800-798-2273 TTY Line: 1-800-735-2900 Fax: 503-345-5770 Mail: FamilyCare Health Plans WHO MAY FILE AN APPEAL
Please follow these procedures:
A Non-Contracting Physician or other Participating Provider who has furnished you a service may file a standard appeal of a denied claim if he/she completes a waiver of payment statement, which says he/she will not bill you regardless of the outcome of the appeal. SUPPORT FOR YOUR APPEAL If you or your provider believes that waiting for a decision under the standard timeframe could place your life, health, or ability to regain maximum function in serious jeopardy you can request an expedited (or “fast”) decision or appeal If FamilyCare Health Plans agrees with your request, we will render a decision as expeditiously as your health condition might require, but no later than 72 hours after receiving your request. The 72-hour period begins when the request is received by FamilyCare Health Plans. In the case of an expedited decision or appeal, you or your authorized representative may submit evidence, in person, via telephone, or in writing transmitted by FAX at the address and telephone number referenced above under the expedited/72-hour review procedure. (Please call FamilyCare Health Plans if you need additional information or assistance regarding the procedures for submitting evidence to support your appeal.) APPEALS MEDICARE STANDARD ORGANIZATION DETERMINATION & APPEALS
PROCEDURES Request for Service. If you request services, or require Prior Authorization of a Referral for services, FamilyCare Health Plans must make a decision as expeditiously as your health requires, but no later than fourteen (14) calendar days after receiving your request for service. An extension of up to fourteen (14) calendar days is permitted, if you request the extension or if we have a need for additional information and the extension of time benefits you; for example, if we need additional medical records from Non-Contracting Medical Providers that could change a denial decision. Request for Payment. If you request payment for services already received,
the Medicare health plan will usually make a decision on whether or If you decide to proceed with the Medicare Standard Appeals Procedure, the following steps will occur: 1. You must submit a written or oral request for reconsideration to the FamilyCare Health Plans Customer Services Department Attn: Customer Service Department at 2121 SW Broadway, Suite 300, Portland, OR 97201. You may also request reconsideration through the Social Security office (or, if you are a railroad retirement beneficiary, through a Railroad Retirement Benefits Office). You must submit your request within sixty (60) calendar days of the date of the notice of the initial decision. An oral request for an appeal must be followed up in writing to the FamilyCare Health Plan unless an expedited appeal is requested. Note: The sixty (60)- day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60)-day time frame. 2. FamilyCare Health Plans will conduct reconsideration and notify you in writing of the decision, using the following time frames: Request for Service. If the appeal is for a denied service, we must notify you of the reconsideration decision as expeditiously as your health requires, but no later than thirty (30) days from receipt of your request. We may extend this time frame by up to fourteen (14) days if you request the extension or if we need additional information, and the extension of time benefits you; for example, if we need additional medical records from Non-Contracting Medical Providers that could change a denial decision. Again, we must make a decision as expeditiously as your health requires, but no later than the end of any extension period. Request for Payment. If the appeal is for a denied claim, FamilyCare Health Plan must notify you of the reconsideration determination no later than sixty (60) days after receiving your request for a reconsideration determination. Our reconsideration decision will be made by a person(s) not involved in the initial decision. All reconsideration of adverse Organization Determinations based on "lack of Medical Necessity" must be made by a Participating Provider with appropriate expertise in the field of medicine appropriate for the services at issue. You or your authorized representative may present or submit relevant facts and/or additional evidence for review either in person or in writing to FamilyCare Health Plans. 3. If we decide fully in your favor on a request for a service, we must
provide or authorize the requested service within thirty (30) days of the
date we 4. If we decide to uphold the original adverse decision, either in whole or in part, we will automatically forward the entire file to an Independent Review Entity for a new and impartial review. The Independent Review Entity is CMS's independent contractor for appeal reviews involving Medicare health plans, like FamilyCare Health Plans. We must send the Independent Review Entity the file within 30 days of a request for services and within 60 days of a request for payment. The Independent Review Entity will either uphold FamilyCare Health Plan's decision or issue a new decision. If we forward the case to the Independent Review Entity, we will notify you of our decision as discussed above. 5. For cases submitted for review, the Independent Review Entity will make a reconsideration decision and notify you in writing of their decision and the reasons for the decision. If the Independent Review Entity upholds our decision, their notice will inform you of your right to a hearing before an Administrative Law Judge of the Social Security Administration (see below for further levels of appeal). If the Independent Review Entity (or a higher appeal level) decides in your favor, we must pay for, provide or authorize the service as expeditiously as your health condition requires, but no later than 60 days from the date we receive notice reversing our decision. • If the Independent Review Entity does not rule in your favor, there are further levels of appeal: • If there is at least $110 in controversy, you may request a hearing before an administrative law judge (ALJ) by submitting a written request to the entity specified in the Independent Review Entity’s reconsideration notice within sixty (60) days of the date of the Independent Review Entity’s notice that the reconsideration decision was not in your favor. This sixty (60) day notice may be extended for good cause. The Independent Review Entity will forward your request and your reconsideration file to the hearing office. FamilyCare Health Plans will also be made a party to the appeal at the ALJ level. • Either you or FamilyCare Health Plans may request a review of an ALJ decision by the Medicare Appeals Council (MAC), which may either review the decision or decline review. • If the amount is $1,090 or more, either you or FamilyCare Health Plans may request that a decision made by the Medicare Appeals Council (MAC), or the ALJ if the MAC has declined review, be reviewed by a Federal district court. • Any initial or reconsidered decision made by FamilyCare Health Plans, the Independent Review Entity, the ALJ, or the MAC can be reopened by any party (a) within one year from the date of the Organization Determination or reconsideration for any reason, (b) within four (4) years for good cause, or (c) at any time for clerical correction of an error or in cases of fraud. 6. The reconsidered determination is final and binding upon the Medicare health plan. If there is a binding arbitration clause in your contract or on your individual election form, it does not apply to disputes subject to CMS ’s appeals process. MEDICARE EXPEDITED 72-HOUR DETERMINATION & APPEAL PROCEDURE You have the right to request and receive expedited (“fast”) decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the time frame of the standard decision- making process could seriously jeopardize your life or health, or your ability to regain maximum function. If FamilyCare Health Plans decides, based on medical criteria, that your situation is Time-Sensitive or if any Participating Provider makes the request for you or calls or writes in support of your request for an expedited review, we will issue a decision as expeditiously as your health requires, but no later than seventy-two (72) hours after receiving the request. Types of Decisions Subject to Expedited 72-Hour Review: 1. Expedited Determinations. If you believe you need a service, or continue
to need a service, and you believe it is a Time-Sensitive situation, you
or 2. Expedited Appeals. If you want to request a reconsideration (appeal)
of a decision by FamilyCare Health Plans to deny a service you requested
or to We may extend this time frame by up to fourteen (14) days if you request the extension or if we need additional information, and the extension of time benefits you; for example, if we need additional medical records from Non-Contracting Medical Providers that could change a denial decision. Again, we must make a decision as expeditiously as your health requires, but no later than the end of any extension period. Examples of service decisions which you may appeal on an expedited basis, when you believe it is a Time-Sensitive situation, include the following: 1. If you received a denial of a service you requested; 2. If you think services are being discontinued too soon. For example: • If you think you are being discharged from a hospital or Skilled Nursing Facility (SNF) too soon. • If you think your comprehensive out patient rehabilitation facility (CORF) is being discontinued too soon. • If you think your Home Health care is being discontinued too soon. • If you think you are being discharged from a hospital, SNF, CORF, or home health agency too soon and you have missed the deadline for a Quality Improvement Organization (QIO) review. The procedures for requesting and receiving an expedited determination or an expedited (“fast”) appeal are described in the following sections. HOW TO REQUEST AN EXPEDITED (“FAST”) 72-HOUR REVIEW To request an expedited/72-hour review, you or your authorized representative may call, write, fax or visit FamilyCare Health Plans. Be sure to ask for an Expedited 72- Hour Review when you make your request. You may call from 8:00 am to 8:00 pm Monday to Friday. Call: Write: Walk-in: HOW YOUR 72-HOUR DETERMINATION REVIEW REQUEST WILL BE PROCESSED 1. Upon receiving your request for an expedited decision the FamilyCare Health Plans will determine if your request meets the definition of Time-Sensitive. If your request does not meet the definition, it will be handled within the standard review process. You will be informed by telephone or in person whether your request will be processed through the expedited seventy-two (72) hour review or the standard review process. You will also be sent a written confirmation within three (3) working days of the phone call or personal contact. If you disagree with FamilyCare Health Plan's decision to process your request within the standard time frame, you may file a grievance with FamilyCare Health Plans. The written confirmation letter will include instructions on how to file a grievance. If your request is Time-Sensitive, you will be notified of our decision as expeditiously as your health requires but no later than seventy-two (72) hours after we receive the request. An extension up to fourteen (14) calendar days is permitted for a 72-hour request for determination/appeal, if you ask for the extension, or we need more information and the extension of time benefits you; for example, if you need time to provide us with additional information or if we need to have additional diagnostic testing completed. 2. Your request must be processed within seventy-two (72) hours if any
physician calls or writes in support of your request for an expedited/ If a Non-Contracting Medical Provider supports your request, FamilyCare Health Plans/Contracting Medical Group or IPA will have 72 hours from the time it receives all the necessary medical information from that Non-Contracting Provider it needs to make a decision. 3. FamilyCare Health Plans will make a decision on your request for determination/appeal
and notify you of it within 72-hours of receipt of your There are four possible dispositions to a request for expedited determination/ appeal. They are: 1. Your request to expedite our determination/appeal decision is approved, we make a decision in 72 hours and notify you that we will provide or continue the service. 2. Your request to expedite our determination/appeal decision is approved, we make a decision in 72 hours and notify you that we will not provide or continue the service. 3. Your request to expedite our determination/appeal decision is not
approved, and we tell you that your request will be handled under the standard 4. Your request to expedite our determination/appeal decision cannot be made in 72 hours, and we let you know that we will need up to an additional 14 days to process your request. We will send correspondence for all determinations. You have a right to appeal this denial. If you have questions regarding these rights, please call: the FamilyCare Health Plans Customer Service Department from 8:00 am to 8:00 pm Monday to Friday. Our Customer Service Representatives are available to help you. FAMILYCARE HEALTH PLANS GRIEVANCE PROCEDURES As a FamilyCare Health Plans Member, you have the right to file a complaint, also called a grievance, about problems you observe or experience, including: • Complaints about the quality of services that you receive. • General dissatisfaction. • A Member’s involuntary disenrollment initiated by FamilyCare Health Plans. • Difficulty getting through on the telephone. • Complaints about the quality of service that you receive. • Complaints regarding such issues as
office waiting times, Participating Provider behavior, adequacy
of facilities, or other similar Member concerns. • If you disagree with our decision to
process your request for a service or to continue a service under
the standard 14-day time frame
rather • If you disagree with our decision to
process your appeal request under the standard 30-day timeframe
rather than the expedited 72-hour time We will attempt to resolve any complaint that you might have. We encourage the informal resolution of complaints (i.e., over the telephone), especially if such complaints result from misinformation, misunderstanding or lack of information. However, if your complaint cannot be resolved in this manner, a more formal Member grievance procedure is available: 1. A complaint or grievance that can be initiated over the telephone,
in writing or in person, will be handled promptly with every attempt made
to 2. Prompt corrective action will be initiated by the appropriate department(s) and/or committee(s) if the complaint is found to be valid. The decision is forwarded to the Member in writing. 3. FamilyCare Health Plans will respond within 24 hours to a Member's grievance that FamilyCare Health Plans extended the time frame to make an organization determination or reconsideration, or refused to grant a request for an expedited Organization Determination or reconsideration. 4. FamilyCare Health Plans will make the Member aware that the grievance should be submitted within a timely fashion. The time for filing a grievance is limited to a period of one year from the occurrence. If you have complaints about a decision regarding payment for or provision of Covered Services that you believe are covered by Medicare and should be provided or paid for by FamilyCare Health Plans your complaints must be appealed through FamilyCare Health Plan's Medicare Appeals Procedure listed above. PEER REVIEW OF THE COMPLAINT PROCESS If you are concerned about the quality of care you have received, you may also file a complaint with the Quality Improvement Organization (QIO) in your state. Acumentra Heatlh SPECIAL PROCEDURE FOR HOSPITAL DISCHARGE DECISIONS You have the right to an immediate Quality Improvement Organization (QIO )review if you believe we have made a decision to discharge you prematurely from the hospital. You will be informed of your right to a QIO review in writing by the hospital when you are admitted, and when you receive a Notice of Discharge and Medicare Appeal Rights (NODMAR) from FamilyCare Health Plans when we issue a discharge notice. The QIO is an organization comprised of practicing doctors and other health care experts who are paid by the Federal Government to monitor and improve the care given to Medicare enrollees. The phone number and address of the Quality Improvement Organization for your area is: Acumentra Heatlh The QIO review is conducted immediately. You are not responsible for hospital charges incurred during the time that the QIO is reviewing the case. The QIO review replaces the appeal process unless you fail to request a QIO review by noon of the first working day after you receive the discharge notice. Then you have the right to request an expedited appeal from the plan. Upon discharge, you have the right to appeal as described above. You may also contact Medicare at 1-800-633-4227 8:00 a.m. to 8:00 p.m. Monday through Friday. Note: You should review your Notice of Discharge and Medicare Appeal
Rightsto verify the address and phone number of the QIO responsible for
the If you ask for immediate review by the QIO by noon on the workday following a Notice of Discharge and Medicare Appeal Rights, you will be entitled to this process instead of the standard appeals process that is described above in this section. You will also be protected from liability for hospital services you received before the QIO makes its decision. Instead of QIO review you may appeal the Notice of Discharge and Medicare Appeal Rights within 60 days as discussed above by requesting that FamilyCare Health Plans reconsider the decision. The advantage of the QIO review is that you will get the results within three working days if you request the review on time. Also, you are not financially liable for hospital charges incurred during the QIO review process. This same protection does not apply in the case of the FamilyCare Health Plans reconsideration process. Note: You may file an oral or written request for an expedited/72-hour
FamilyCare Health Plans appeal only if you have missed the deadline for SPECIAL PROCEDURE FOR SERVICE TERMINATION DECISIONS FOR SKILLED
NURSING FACILITIES, HOME HEALTH AGENCIES OR You have the right to an immediate QIO review if you believe we have made a decision to terminate these services prematurely. You will be informed of your right to QIO review in writing by the provider when you start services with the provider if the services are for a period of less than 2 days. If the service is for more than 2 days, you will receive the notice 2 days prior to the termination of the service. If you want to appeal the decision, you will receive the notice which is entitled, "Notice of Medicare Non-Coverage". You may apply for an immediate review by the QIO. The QIO review is conducted immediately. If you stop services no later than the date indicated on the form, you will avoid financial liability. The QIO review replaces the appeal process unless you fail to request a QIO review by noon of the first working day after you receive the discharge notice. Then you have the right to request an expedited appeal from the plan. (An expedited appeal is explained previously in this document.) If you have any questions about the grievance or appeals process, please call the FamilyCare Health Plans Customer Service Department from Monday through Friday from 8:00 am until 8:00 pm: 503-345-5702 GLOSSARY OF TERMS Complaint – Any expression of dissatisfaction to a Medicare health
plan. provider, facility or Quality Improvement Organization (QIO) by a
Member made orally or in writing. This can include concerns about the operations
of providers, or Medicare health plans such as: Waiting times, the demeanor
of health care personnel, the adequacy of facilities, the respect paid
to Members, the right of the Member to receive services or receive payment
for services previously rendered. It also includes the plans’ refusal
to provide services the Member believes he or she is entitled. A
complaint could be either a grievance or an appeal, or a single complaint
could include
elements of both. Every complaint must be handled under the appropriate
grievance or appeal process. Independent Review Entity – An independent entity contracted by CMS to review Medicare health plans’ denial of coverage determinations and organization determinations. Inquiry – Any oral or written request to an Medicare health plan, provider, or facility, without an expression of dissatisfaction, e.g., a request for information or action by a Member. Medical Director – A licensed physician who is an employee of FamilyCare Health Plans and is responsible for the overall quality of the medical care we provide. Medically Necessary – Medical Services or Hospital Services, which are determined by FamilyCare Health Plans to be: • Rendered for the treatment or diagnosis of an injury or illness and • Appropriate for the symptoms, consistent with diagnosis, and otherwise in accordance with sufficient scientific evidence and professionally recognized standards and • Not furnished primarily for the convenience of the Member, the attending Physician, or other Provider of service. Whether there is "sufficient scientific evidence" shall be determined by FamilyCare Health Plans based upon the following: peer reviewed medical literature; publications, reports, evaluations and regulations issued by state and federal government agencies, Medicare local carriers and intermediaries; and such other authoritative medical sources as deemed necessary by FamilyCare Health Plan. Organization Determination – Any decision made by or on behalf of a Medicare Advantage organization regarding payment or services to which a Member believes he or she is entitled. Quality Improvement Organization (QIO) – Organizations comprised of practicing doctors and health care experts under contract to the Federal government to monitor and improve the care given to Medicare Members. They review complaints raised by Members about the quality of care provided by physicians, inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare managed care plans, and ambulatory surgical centers. The QIOs also review continued-stay denials in acute inpatient hospitals. Skilled Nursing Care – Services that can only be performed by, or under the supervision of licensed nursing personnel. Skilled Nursing Facility – A facility that provides inpatient Skilled Nursing Care, rehabilitation services or other related health services and is certified by Medicare. The term "Skilled Nursing Facility" does not include a convalescent nursing home, rest facility or facility for the aged that furnishes primarily Custodial Care, including training in routines of daily living. Time-Sensitive – A situation where waiting for a standard decision could seriously jeopardize your life or health, or your ability to regain maximum function. How to Obtain Information on Grievances, Appeals, and Exceptions A grievance is a complaint that a Medicare member makes about the way FamilyCare Health Plans provides care (other than complaints about requests for service or payment.) A grievance about quality of care is one kind of grievance. For example, a member can file a grievance about the quality of care when the member believes that the service the he or she received was not timely or correct, when the member had problems getting a service because of long waiting times or long travel distances, or when the wrong kind of doctor or hospital provided the service. An appeal is a formal complaint about FamilyCare Health Plans’ decision not to pay for, not to provide, or to stop an item or service that a Medicare member believes he or she needs. If a member cannot get an item or service that the member feels s/he needs, or if the health plan has denied payment of a claim for service the member has already received the member can appeal. A Medicare member can request that FamilyCare Health Plans review the member’s appeal quickly if the member believes that his health could be seriously harmed by waiting for a decision about an appeal. This is called a request for an expedited or “fast” appeal. If you would like a copy of the most recent report on FamilyCare’s response to quality of care grievances, appeals, and requests for exceptions you may contact us in any of the following ways: Phone: 503-345-5777 (Compliance Hotline. Please leave a message.) |
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