Grievance and Appeals Facts 2014

As a member of one of our BlueCHiP for Medi­care health plans, we encourage you to let us know right away if you have questions, con­cerns, or problems about your covered services or the care you receive.

Federal law guarantees that you have the right to make a complaint if you have concerns or problems with any part of your care as a plan member. Please be assured that you cannot be disenrolled from BlueCHiP for Medicare or penalized in any way if you make a complaint.

Below is an overview of the Grievance & Appeals Process. It includes infor­mation on how to make a complaint about Part C medical services and benefit issues, as well as what to do if you have a complaint about your Part D prescription drug coverage.

For a thorough and detailed explanation of the complaint process, we suggest that you review the Grievance and Appeals Sections in the Evidence of Coverage manual. Click on the links below to see the Evidence of Coverage manual for your plan:

BlueCHiP for Medicare Value Evidence of Coverage
BlueCHiP for Medicare Standard with Drugs Evidence of Coverage
BlueCHiP for Medicare Plus Evidence of Coverage
BlueCHiP for Medicare Preferred Evidence of Coverage
BlueCHiP for Medicare Core Evidence of Coverage
BlueCHiP for Medicare Group Plus Evidence of Coverage
BlueCHiP for Medicare Group Preferred Evidence of Coverage
BlueCHiP for Medicare Group Preferred Unlimited Evidence of Coverage

There are different types of complaints that you can file with the Plan. Depending on the subject of the complaint, it can be handled as a grievance, an appeal, or it may require that the Plan make an initial decision. We will first dis­cuss grievances.

Please note: Any process relative to Part D prescription drugs does not apply to members with BlueCHiP for Medicare Core (HMO) because the Plan does not include Part D prescription drug coverage.

Grievances

What is a grievance?
A “grievance” is any type of complaint you make about your BlueCHiP for Medicare Plan or one of our network providers or network pharmacies. A grievance can also include a complaint you may have about the quality of care you receive. Please note that this type of complaint does not involve coverage or pay­ment disputes.

What type of problems might lead to your filing a grievance?
These are some examples:
• Problems with the quality of the medical care you receive.
• Problems with the customer service you receive.
• Problems with how long you have to spend waiting on the phone, in the waiting room, in a network pharmacy, or in the exam room.
• Disrespectful or rude behavior by doctors, nurses, network pharmacists, or other staff.

If you have problems of this type and want to make a complaint, it is called “filing a grievance.”

Filing a grievance with our Plan
If you have a complaint, you or your represen­tative may contact BlueCHiP for Medicare’s Customer Service directly by calling the phone number in the Contact Information section at the end of this page. Every attempt will be made to resolve your complaint over the phone. If you request a written response to your phone complaint, we will respond in writ­ing to you. Also, if you file a written grievance, or your complaint is related to quality of care, a response will be sent to you in writing.

If your complaint cannot be resolved over the phone, the Plan has a formal procedure to review your complaint. It is called the Medicare grievance process. The grievance must be submitted within 60 days of when the event or incident occurred. Based on the condition of your health, your grievance must be addressed as quickly as your case requires, but no later than 30 days after we receive your complaint. The Plan may extend the time frame by up to 14 days if you ask for the extension, or if additional information is needed and the delay is in your best interest.

If you are not satisfied with the resolution of your grievance, you will be advised of any dis­pute resolution options you may have.

Initial Determinations (Decisions)

What is an initial determination?
An initial determination is a decision made by the Plan about a specific problem you have. You need to request that an initial determination (decision) be made by the Plan if you are having problems getting:
• The Part C medical care or services you need
• The Part D prescription drugs you need
• Payment for a Part D drug or Part C service you have already received

There are different types of determinations based on the type of service involved. If it is related to Part C medical services and benefits, it is called an organization determination. If it is related to a Part D prescription drug problem, it is called a coverage determination. We will discuss each type separately.

These are some examples of issues you may have relative to Part C medical services and benefits:
• You are not getting the Part C medical care or services you want, and you believe that this care is covered by the Plan.
• We will not approve the medical treatment your doctor or other medical provider wants to give you, and you believe that this treat­ment is covered by the Plan.
• You are being told that a medical treatment or service you have been getting will be reduced or stopped, and you believe that this could harm your health.
• You feel you are being discharged from the hospital too soon, or your coverage for skilled nursing facility (SNF), home health agency (HHA), or comprehensive outpatient rehabilitation facility (CORF) services are ending too soon.

If you have an issue of this type, you, your doc­tor, or other medical provider must request that the Plan make an organization determination on your behalf, or you can name (appoint) some­one to do it for you.

These are some examples of issues you may have relative to your Part D prescription drug benefits that would require a coverage deter­mination:

  • You ask the Plan to pay for a prescription drug you have already received.
  • You ask the Plan to pay you back for the cost of a drug you bought at an out­of­network pharmacy.
  • You ask for a Part D drug that is not on the formulary. This is a request for a “formulary exception.”

If you have an issue of this type, you, your doctor, or another provider may ask for an initial decision (in this case a coverage determination) on your behalf, or you can name (appoint) someone to do it for you.

An “exception” is a type of coverage deter­mination. You or your doctor may ask for an exception to our Part D coverage rules in a number of situations such as:

  • Asking the Plan to cover your drug even if it is not on the formulary.
  • Asking the Plan to waive coverage restrictions or limits on your drug.
  • Asking the Plan for a non­preferred Part D drug at the preferred cost­sharing level. This is a request for a “tiering exception.”

“Standard” or “fast” decisions can be requested after an initial determination has been made for either Part C medical services and benefits or Part D prescription drug benefits. You, your doctor,or your representative may ask for a “standard” or “fast” decision, depending on your health, by calling, faxing, or writing the plan. Please see contact information at the end of this section.

Appeals
An appeal is a special kind of complaint you make if you disagree with a decision (determi­nation) made by the Plan. This is called a “re­consideration” if it is about Part C medical care or services. It is called a “redetermination” if it is about a Part D prescription drug issue.

For example, you may disagree with the de­cision (determination) that your request for healthcare services was denied, your request for prescription drugs or payment for services was denied, or reimbursement for prescription drugs you have already received was denied. There can be several levels to the appeal process, and it may be reviewed by an inde­pendent review organization. Please refer to the Evidence of Coverage manual for a complete explanation of the appeal process. You also have the right to ask us for a copy of the infor­mation regarding your appeal.

An appeal to the Plan about a Part C medical care or service organization determination is called a plan “reconsideration.” You, your doctor, or other medical provider may file an appeal of the initial determination (decision), or you can name (appoint) someone to do it for you. However, providers who do not have a contract with our Plan may also appeal a pay­ment decision as long as that provider signs a “waiver of payment” statement saying they will not ask you to pay for the Part C medical care or service under review, regardless of the outcome of the appeal.

An appeal to the plan about a Part D prescrip­tion drug coverage determination is called a prescription drug plan “redetermination.” You, your doctor, or other medical provider may file an appeal of the initial determination (decision), or you can name (appoint) someone to do it for you.

Filing an appeal with our Plan
You may ask for a “standard” or “fast/expe­dited” appeal, depending on your health. To ask for a standard appeal about a Part C medical care or service issue or a Part D pre­scription drug issue, a signed, written appeal request must be sent to the Plan. Please see contact information at the end of this section. Only “fast/expedited” appeals may be done verbally over the phone.

How soon must you file your appeal?
You must file the appeal request within 60 cal­endar days from the date that appears on the notice of the initial determination you receive. We may give you more time if you have a good reason for missing the deadline. Please be sure to indicate the reason for missing the deadline in your written appeal request.
 

Contact Information

Part C Grievance & Appeals (about your medical care and services) Part D Grievance & Appeals (about your Part D prescription drugs)

CALL: 1-800-267-0439. Calls to this number are free.

TTY/TDD (Telecommunications Device for the Deaf): 1-877-232-8432. This number requires special telephone equipment. Calls to this number are free.

Our Customer Service hours are: October 15, 2011 – February 14, 2012: Seven days a week, 8:00a.m. to 8:00 p.m.; February 15, 2012 until the following annual enrollment period, Monday – Friday, 8:00 a.m. to 8:00 p.m.

FAX: 1-866-884-9475

WRITE:
Blue Cross & Blue Shield of Rhode Island
Grievance and Appeals Unit: BlueCHiP for Medicare
500 Exchange Street
Providence, RI 02903

Part C Organization Determinations

CALL: 1-800-267-0439. Calls to this number are free.

TTY/TDD (Telecommunications Device for the Deaf): 1-877-232-8432. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Our Customer Service hours are: October 15, 2011 - February 14, 2012: Seven days a week, 8:00a.m. to 8:00 p.m.; February 15, 2012 until the following annual enrollment period, Monday – Friday, 8:00 a.m. to 8:00 p.m.
FAX: (401) 459-5089

WRITE:
Blue Cross & Blue Shield of Rhode Island
Grievance and Appeals Unit: BlueCHiP for Medicare
500 Exchange Street
Providence, RI 02903

Part D Coverage Determinations

CALL: 1-800-294-5979. Calls to this number are free.

TTY/TDD (Telecommunications Device for the Deaf): 1-800-863-5488. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Hours of operation are: 7:00 a.m. to 11:00 p.m., seven days a week.

FAX: (401) 459-5089

WRITE:
Caremark Appeals Department
PO Box 52000
Phoenix, AZ 85072

If you have any other questions, please contact BlueCHiP for Medicare Customer Service at 1-800-267-0439. TTY/TDD (Telecommunications Device for the Deaf) users should call 1-877-232-8432. Customer Service hours are: October 15, 2011 - February 14, 2012 – Seven days a week, 8:00 a.m. to 8:00 p.m.; February 15, 2012 until the following annual enrollment period - Monday through Friday, 8:00 a.m. to 8:00 p.m.

Last updated: 01/15/2014

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