Our Appeals and Grievances Process
The following procedures for appeals and grievances must be followed by your Medicare Advantage health plan in identifying, tracking, resolving and reporting all activity related to an appeal or grievance.

Member Appeals
Who Can File an Appeal?
An appeal may be filed by any of the following:

• You may file an appeal.
• Someone else may file the appeal for you on your behalf.

You may appoint an individual to act as your representative to file the appeal for you by following the steps below:

• Provide your Medicare Advantage health plan with your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: “I [your name] appoint [name of representative] to act as my representative in requesting an appeal from your Medicare Advantage health plan and/or CMS regarding the denial or discontinuation of medical services.”
• Provide your name, address and phone number and that of your representative, if applicable.
• You must sign and date the statement.
• Your representative must also sign and date this statement.
• You must include this signed statement with your appeal. MHNet offers an appeal process if you are not satisfied with a care advocacy or claims payment decision related to behavioral health services. There is also a complaint process MHNet or your behavioral health practitioner. Complaints and appeals may be filed over the phone or in writing.

What Is an Appeal?

An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your Medicare Advantage health plan pays or will pay for a service or the amount you must pay for a service.

When Can an Appeal Be Filed?

You may file an appeal within sixty (60) calendar days of the date of the notice of the initial organization determination. For example, you may file an appeal for any of the following reasons:

• Your Medicare Advantage health plan refuses to cover or pay for services you think your Medicare Advantage health plan should cover.
• Your Medicare Advantage health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
• Your Medicare Advantage health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
• If you think that your Medicare Advantage health plan is stopping your coverage too soon.

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 timeframe.

Where Can an Appeal Be Filed?

An appeal may be filed in writing directly to us or contacting Customer Service at at 1-866-550-4736 (TTY: 711), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday. You may also contact Customer Service and request the facsimile number for Appeals and Grievances.

Why File an Appeal?

You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your Medicare Advantage health plan paid for a service.

What Do I Include With My Appeal?

You should include: your name, address, member ID number, reasons for appealing, and any evidence you wish to attach. You may send in supporting medical records, doctors’ letters, or other information that explains why your plan should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.

What Happens Next?

If you appeal, we will review the decision. If any of the services you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by a reviewer outside of our Organization or Prescription Drug Plan. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited 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 timeframe of the standard decision-making process could seriously jeopardize:

• your life or health, or
• your ability to regain maximum function.

If your Medicare Advantage health plan or your Primary Care Physician decides, based on medical criteria that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan or your Primary Care Physician will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request.

You have the right to request the aggregate number of grievances, appeals and Part D exceptions filed with Physicians Health Choice. Call Customer Service at 1-866-550-4736 (TTY 711), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, for more information.