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Grievance and Appeals Process
If you are a member of Mercy MedicareADVANTAGE HMO or PPO, and you have a
concern about your health plan, the quality of your care, or your coverage for certain
services; you may file a grievance or appeal to resolve your concern. Your coverage will
not be impacted and you cannot be disenrolled or penalized in any way if you make a
complaint. You may also find this information in the Evidence of Coverage.
What is a Grievance?
A grievance is a type of complaint you make about us, one of our network providers or
pharmacies, including a complaint concerning the quality of your care. This type of
complaint does not involve coverage or payment disputes.
What is an Appeal?
An appeal is something you do if you disagree with a decision to deny a request for
health care services or prescription drugs or payment for services or drugs you already
received. You may also make an appeal if you disagree with a decision to stop services
that you are receiving. For example, you may ask for an appeal if our Plan doesn’t pay
for a drug, item, or service you think you should be able to receive.
What types of problems might lead to filing a grievance?
- Problems with the service you receive from our Customer Contact Center or other representatives of our plan.
- If you feel that you are being encouraged to leave (disenroll from) the Plan.
- If you disagree with our decision not to give you a "fast" decision or a "fast" appeal.
- We do not provide you a decision within the required time frame.
- We do not provide you required notices.
- You believe our notices and other written materials are hard to understand.
- We do not forward your medical case to the Independent Review Entity if we do not give you a decision on time.
- Problems with the quality of the medical care or services you receive, including quality of care during a hospital stay.
- Problems with how long you have to wait on the phone, in the waiting room, in the exam room or at the pharmacy.
- Problems getting appointments when you need them, or waiting too long for them.
- Rude behavior by doctors, nurses, receptionists, pharmacists, or other staff.
- Cleanliness or condition of doctor's offices, clinics, hospitals, or pharmacies.
Who may file a grievance?
You or someone you name may file a grievance.
Appointing a Representative
The person you name would be your “representative.” You may name a relative, friend,
lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be
authorized by the Court or in accordance with State law to act for you. If you want
sign and date a statement that gives the person legal permission to be your representative.
If you would like to appoint a person to file a grievance, request a coverage
determination, or request an appeal on your behalf, you and the person accepting the
appointment must fill out this form (or a written equivalent) and submit it with the
request. The form can be found at the following web address:
http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf. Or, you can call our
Customer Contact Center at the number on your ID card for a form. Send the completed
form to: Mercy MedicareADVANTAGE, 14528 S. Outer 40, Ste. 300, Chesterfield, MO 63017
Filing a grievance with our Plan
If you have a complaint, you or your representative may call us. We will try to resolve
your complaint over the phone. If you ask for a written response, file a written grievance,
or your complaint is related to quality of care, we will respond in writing to you. If we
cannot resolve your complaint over the phone, we have a formal procedure to review your complaints.
The grievance must be submitted within sixty (60) days of the event or incident. We will
write to let you know how we have addressed your concern within 20 calendar days of
receiving your written grievance. We must address your grievance as quickly as your
case requires based on your health status, but no later than thirty (30) days after
receiving your complaint. We may extend the time frame by up to fourteen (14) days if
you ask for the extension, or if we justify a need for additional information and the delay
is in your best interest. If we deny your grievance in whole or in part, our written
decision will explain why we denied it, and will tell you about any dispute resolution
options you may have.
Fast Grievances
In certain cases, you have the right to ask for a "fast grievance," meaning we will
answer your grievance within twenty-four (24) hours.
Appeals about your Part C Medical Care/Service(s) and Part D Prescription
Drug Coverage (for members with Part D coverage)
Initial Determinations
The initial determination we make is the starting point for dealing with requests you may
have about covering a Part C medical care or service you need, paying for a Part C
medical care or service you already received, covering a Part D drug you need, or
paying for a Part D drug you already received. Initial decisions about Part C medical
care or services are called "organization determinations." With this decision, we explain
whether we will provide the Part C medical care or service you are requesting, or pay
for the Part C medical care or service you already received.
The following are examples of requests for initial determinations:
- You are not getting medical care/services or drug 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 have received Part C medical care or services that you believe should be
covered by the Plan, but we have refused to pay for this care.
- You ask for a Part D drug that is not on your plan sponsor's list of covered drugs
(called a "formulary"). This is a request for a "formulary exception."
- You ask for an exception to our utilization management tools - such as prior authorization, dosage limits, or quantity limits. Requesting an exception to a utilization management tool is a type of formulary exception.
- You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a
request for a "tiering exception."
The Evidence of Coverage has detailed information on how to request reimbursement
for a drug that you have already paid for and received.
What is an exception?
An exception is a type of initial determination (also called a “coverage determination”)
involving a Part D drug. You or your doctor may ask us to make an exception to our Part
D coverage rules in a number of situations.
Your doctor must submit a statement supporting your exception request. In order to help
us make a decision more quickly, the supporting medical information from your doctor
should be sent to us with the exception request.
If we approve your exception request, our approval is valid for the remainder of the Plan
year, so long as your doctor continues to prescribe the Part D drug for you and it
continues to be safe for treating your condition. If we deny your exception request, you
may appeal our decision.
Note: If we approve your exception request for a Part D non-formulary drug, you cannot
request an exception to the copayment or coinsurance amount we require you to pay for
the drug.
- You may ask us to cover your Part D drug even if it is not on our formulary. Excluded
drugs cannot be covered by a Part D plan.
- You may ask us to waive coverage restrictions or limits on your Part D drug. For
example, for certain Part D drugs, we limit the amount of the drug that we will cover.
If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
- You may ask us to provide a higher level of coverage for your Part D drug. If your
Part D drug is contained in our third tier, non-preferred brand Part D drug tier, you
may ask us to cover it at the cost-sharing amount that applies to drugs in the second
tier, preferred brand Part D drug tier instead. This would lower the co-payment
amount you must pay for your Part D drug.
Who may ask for an initial determination?
You, your prescribing physician, or someone you name may ask us for an initial
determination. The person you name would be your “appointed representative.” See the
previous section “Appointing a Representative” to learn how to do this.
You also have the right to have a lawyer act for you. You may contact your own lawyer,
or get the name of a lawyer from your local bar association or other referral service.
There are also groups that will give you free legal services if you qualify.
Asking for a "standard" or "fast" initial determination
A decision about whether we will give you, or pay for medical care/service or drug you
are requesting can be a “standard" decision that is made within the standard timeframe
or it can be a "fast" decision that is made more quickly. A fast decision is also called an
"expedited" decision.
Asking for a standard decision
To ask for a standard decision for a medical care/service or drug you, your doctor, or
your representative should fax, or write us at the numbers or address listed in the
section "How to file an appeal".
Asking for a fast decision
You may ask for a fast decision only if you or your doctor believe that waiting for a
standard decision could seriously harm your health or your ability to function. (Fast
decisions apply only to requests for benefits that you have not yet received. You cannot
get a fast decision if you are asking us to pay you back for a benefit that you already
received.)
Be sure to ask for a "fast" or "expedited" review. If your doctor asks for a fast decision
for you, or supports you in asking for one, and the doctor indicates that waiting for a
standard decision could seriously harm your health or your ability to function, we will
automatically give you a fast decision.
If you ask for a fast decision without support from a doctor, we will decide if your health
requires a fast decision. If we decide that your medical condition does not meet the
requirements for a fast decision, we will send you a letter informing you that if you get a
doctor’s support for a fast review, we will automatically give you a fast decision. The
letter will also tell you how to file a "fast grievance." You have the right to file a fast
grievance if you disagree with our decision to deny your request for a fast review. If we
deny your request for a fast initial determination, we will give you a standard decision.
What happens when you request an initial determination?
- For a decision about payment for medical care or services you already received, if
we do not need more information to make a decision, we have up to thirty (30) days to make a decision after we receive your request. However, some decisions may
take longer. If we need more information in order to make a decision, we have up to
sixty (60) days from the date of the receipt of your request to make a decision. You
will be told in writing when we make a decision. If you have not received an answer
from us within sixty (60) days of your request, you have the right to appeal.
- For a standard decision about Part C medical care or services you have not yet
received, we have fourteen (14) days to make a decision after we receive your
request. However, we can take up to fourteen (14) more days if you ask for
additional time, or if we need more information (such as medical records) that may
benefit you. If we take additional days, we will notify you in writing. If you believe that
we should not take additional days, you can make a specific type of complaint called
a "fast grievance". If you have not received an answer from us within fourteen (14)
days of your request (or by the end of any extended time period), you have the right
to appeal.
- For a fast decision about Part C medical care or services you have not yet received,
we will give you our decision about your requested medical care or services within
seventy-two (72) hours after we receive the request. However, we can take up to
fourteen (14) more days if we find that some information is missing that may benefit
you, or if you need more time to prepare for this review. If we take additional days,
we will notify you in writing. If you believe that we should not take any extra days,
you can file a fast grievance. We will call you as soon as we make the decision. If we
do not tell you about our decision within seventy-two (72) hours (or by the end of any
extended time period), you have the right to appeal. If we deny your request for a
fast decision, you may file a "fast grievance."
- For a standard initial determination about a Part D drug (including a request to pay
you back for a Part D drug that you have already received), we must give you our
decision no later than seventy-two (72) hours after we receive your request, but we
will make it sooner if your request is for a Part D drug that you have not received yet
and your health condition requires us to. However, if your request involves a request
for an exception (including a formulary exception, tiering exception, or an exception
from utilization management rules – such as prior authorization, dosage limits, or
quantity limits, we must give you our decision no later than seventy-two (72) hours
after we receive your physician's "supporting statement" explaining why the drug you
are asking for is medically necessary. If you have not received an answer from us
within seventy-two (72) hours after we receive your request (or your physician's
supporting statement if your request involves an exception), your request will
automatically go to Appeal Level 2.
- For a fast initial determination about a Part D drug that you have not yet received,
we will give you our decision within twenty-four (24) hours after you or your doctor
ask for a fast review. We will give you the decision sooner if your health condition
requires us to. If your request involves a request for an exception, we will give you
our decision no later than twenty-four (24) hours after we have received your
physician's "supporting statement," which explains why the drug you are asking for is
medically necessary. If we decide you are eligible for a fast review and you have not
received an answer from us within twenty-four (24) hours after receiving your request (or your physician's supporting statement if your request involves an
exception), your request will automatically go to Appeal Level 2.
What happens if we decide completely in your favor?
- For a decision about payment for Part C medical care or services you already
received, we generally must send payment no later than thirty (30) days after we
receive your request. However, a small number of decisions may take up to sixty
(60) days. If we need more information in order to make a decision, we have up to
sixty (60) days from the date of the receipt of your request to make payment.
- For a standard decision about Part C medical care or services you have not yet
received, we must authorize or provide your requested care within fourteen (14)
days of receiving your request. If we extended the time needed to make our
decision, we will authorize or provide your medical care before the extended time
period expires.
- For a fast decision about Part C medical care or services you have not yet received,
we must authorize or provide your requested care within seventy-two (72) hours of
receiving your request. If we extended the time needed to make our decision, we will
authorize or provide your medical care before the extended time period expires.
- For a standard decision about a Part D drug (including a request to pay you back for
a Part D drug that you have already received), we must cover the Part D drug you
requested as quickly as your health requires, but no later than seventy-two (72)
hours after we receive the request. If your request involves a request for an
exception, we must cover the Part D drug you requested no later than seventy-two
(72) hours after we receive your physician's "supporting statement." If you are asking
us to pay you back for a Part D drug that you already paid for and received, we must
send payment to you no later than thirty (30) calendar days after we receive the
request (or supporting statement if your request involves an exception).
- For a fast decision about a Part D drug that you have not yet received, we must
cover the Part D drug you requested no later than 24 hours after we receive your
request. If your request involves a request for an exception, we must cover the Part
D drug you requested no later than twenty-four (24) hours after we receive your
physician's "supporting statement."
What happens if we decide against you?
If we decide against you, we will send you a written decision explaining why we denied
your request. If an initial determination does not give you all that you requested, you
have the right to appeal the decision.
Appeal Level 1: Appeal to the Plan
An appeal to the plan about Part C medical care or services is also called a plan
"reconsideration." An appeal to the plan about a Part D drug is also called a plan
"redetermination."
Who may file your appeal of the initial determination?
If you are appealing an initial decision about Part C medical care or services, the rules
about who may file an appeal are the same as the rules about who may ask for an
organization determination.
If you are appealing an initial decision about a Part D drug, you, your representative, or
your doctor may file a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within sixty (60) calendar days from the date included
on the notice of our initial determination. We may give you more time if you have a good
reason for missing the deadline.
How to file your appeal?
Asking for a standard appeal: To ask for a standard appeal about a medical care/
service or drug, a signed, written appeal request must be sent to: Mercy
MedicareADVANTAGE, Customer Contact Center, 14528 S. Outer 40, Ste. 300,
Chesterfield, MO 63017
Asking for a fast appeal: If you are appealing a decision we made about giving you a
medical care/service or drug that you have not received yet, you and/or your doctor will
need to decide if you need a fast appeal. You, your doctor, or your representative may
ask us for a fast appeal by calling the number on your ID Card, faxing, or writing us at:
Mercy MedicareADVANTAGE, Customer Contact Center, 14528 S. Outer 40, Ste. 300,
Chesterfield, MO 63017, Fax 314-214-3233
To make a request for a fast appeal for medical care/service or drug outside of regular
weekday business hours, please call our Customer Contact Center and leave a detailed
message. Requests received outside of regularly scheduled business hours will receive
priority attention the next business day. Be sure to ask for a "fast" or "72-hour" review.
Remember, if your doctor provides a written or oral supporting statement explaining that
you need the fast appeal, we will automatically give you a fast appeal. If you ask for a
fast decision without support from a doctor, we will decide if your health requires a fast
decision. If we decide that your medical condition does not meet the requirements for a
fast decision, we will send you a letter informing you that if you get a doctor’s support for
a fast review, we will automatically give you a fast decision. The letter will also tell you
how to file a "fast grievance." You have the right to file a fast grievance if you disagree
with our decision to deny your request for a fast review. If we deny your request for a
fast appeal, we will give you a standard appeal.
How soon must we decide on your appeal?
- For a decision about payment for Part C medical care or services you already
received, we have sixty (60) days to decide after we receive your appeal request. If
we do not decide within sixty (60) days, your appeal automatically goes to Appeal
Level 2.
- For a standard decision about Part C medical care or services you have not yet
received, we have thirty (30) days to decide after we receive your appeal. We will decide sooner if your health condition requires. However, if you ask for more time, or
if we find that helpful information is missing, we can take up to fourteen (14) more
days to make our decision. If we do not tell you our decision within thirty (30) days
(or by the end of the extended time period), your request will automatically go to
Appeal Level 2.
- For a fast decision about Part C medical care or services you have not yet received,
we have seventy-two (72) hours to decide after we receive your appeal. We will
decide sooner if your health condition requires. However, if you ask for more time, or
if we find that helpful information is missing, we can take up to fourteen (14) more
days to make our decision. If we do not decide within seventy-two (72) hours (or by
the end of the extended time period), your request will automatically go to Appeal
Level 2.
- For a standard decision about a Part D drug (including a request to pay you back for
a Part D drug that you have already received), we must cover the Part D drug you
requested as quickly as your health requires, but no later than seven (7) calendar
days after we receive the request. If you are asking us to pay you back for a Part D
drug that you already paid for and received, we must send payment to you no later
than thirty (30) calendar days after we receive the request.
- For a fast decision about a Part D drug that you have not yet received, we must
cover the Part D drug you requested no later than seventy-two (72) hours after we
receive your request.
What happens if we decide completely in your favor?
- For a decision about payment for Part C medical care or services you already
received, we must pay within sixty (60) days of receiving your appeal request.
- For a standard decision about Part C medical care or services you have not yet
received, we must authorize or provide your requested care within thirty (30) days of
receiving your appeal request. If we extended the time needed to decide your
appeal, we will authorize or provide your requested care before the extended time
period expires.
- For a fast decision about Part C medical care or services you have not yet received,
we must authorize or provide your requested care within seventy-two (72) hours of
receiving your appeal request. If we extended the time needed to decide your
appeal, we will authorize or provide your requested care before the extended time
period expires.
- For a standard decision about a Part D drug (including a request to pay you back for
a Part D drug that you have already received), we must cover the Part D drug you
requested as quickly as your health requires, but no later than seven (7) calendar
days after we receive the request. If you are asking us to pay you back for a Part D
drug that you already paid for and received, we must send payment to you no later
than thirty (30) calendar days after we receive the request.
- For a fast decision about a Part D drug that you have not yet received, we must
cover the Part D drug you requested no later than seventy-two (72) hours after we
receive your request.
Appeal Level 2: Independent Review Entity (IRE)
At the second level of appeal, your appeal is reviewed by an outside, Independent
Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid
Services (CMS), the government agency that runs the Medicare program. The IRE has
no connection to us. You have the right to ask us for a copy of your case file that we
sent to this entity.
How to file your appeal?
If you asked for Part C medical care or services, or payment for Part C medical care or
services, and we did not rule completely in your favor at Appeal Level 1, your appeal is
automatically sent to the IRE.
If you asked for Part D drugs and we did not rule completely in your favor at Appeal
Level 1, you may file an appeal with the IRE. If you choose to appeal, you must send
the appeal request to the IRE. The decision you receive from the plan (Appeal Level 1)
will tell you how to file this appeal, including who can file the appeal and how soon it
must be filed.
How soon must the IRE decide?
The IRE has the same amount of time to make its decision as the plan had at Appeal
Level 1.
If the IRE decides completely in your favor:
The IRE will tell you in writing about its decision and the reasons for it.
- For a decision about payment for Part C medical care or services you already
received, we must pay within thirty (30) days after we receive notice reversing our
decision.
- For a standard decision about Part C medical care or services you have not yet
received, we must authorize your requested Part C medical care or service within 72
hours, or provide it to you within fourteen (14) days after we receive notice reversing
our decision.
- For a fast decision about Part C medical care or services, we must authorize or
provide your requested Part C medical care or services within seventy-two (72)
hours after we receive notice reversing our decision.
- For a decision to pay you back for a Part D drug you already paid for and received,
we must send payment to you within thirty (30) calendar days from the date we
receive notice reversing our decision.
- For a standard decision about a Part D drug you have not yet received, we must
cover the Part D drug you asked for within seventy-two (72) hours after we receive
notice reversing our decision.
- For a fast decision about a Part D drug you have not yet received, we must cover
the Part D drug you asked for within twenty-four (24) hours after we receive notice
reversing our decision.
Appeal Level 3: Administrative Law Judge (ALJ)
If the IRE does not rule completely in your favor, you or your representative may ask for
a review by an Administrative Law Judge (ALJ) if the dollar value of the Part C medical
care or service you asked for meets the minimum requirement provided in the IRE’s
decision. During the ALJ review, you may present evidence, review the record (by either
receiving a copy of the file or accessing the file in person when feasible), and be
represented by counsel.
How to file your appeal?
The notice from the IRE will explain how and where to file an appeal with the ALJ. The
request must be filed in writing within sixty (60) calendar days of the date you were
notified of the decision made by the IRE (Appeal Level 2). You can use the form at the
following web address:
http://www.cms.hhs.gov/cmsforms/downloads/CMS20034AB.pdf.
Or, you can call Our
Customer Contact Center at the number on your ID card and we will send this form to you.
The ALJ will not review your appeal if the dollar value of the requested Part C medical
care or service does not meet the minimum requirement specified in the IRE's decision.
If the dollar value is less than the minimum requirement, you may not appeal any
further.
How soon will the Judge make a decision?
The ALJ will hear your case, weigh all of the evidence, and make a decision as soon as
possible.
Appeal Level 4: Medicare Appeals Council (MAC)
If the ALJ does not rule completely in your favor, you or your representative may ask for
a review by the Medicare Appeals Council (MAC).
How to file your appeal?
The request must be filed with the MAC within sixty (60) calendar days of the date you
were notified of the decision made by the ALJ (Appeal Level 3). The MAC may give you
more time if you have a good reason for missing the deadline. The decision you receive
from the ALJ will tell you how to file this appeal, including who can file it.
How soon will the Council make a decision?
The MAC will first decide whether to review your case (it does not review every case it
receives). If the MAC reviews your case, it will make a decision as soon as possible. If it
decides not to review your case, you may request a review by a Federal Court Judge
(see Appeal Level 5). The MAC will issue a written notice explaining any decision it
makes. The notice will tell you how to request a review by a Federal Court Judge.
Appeal Level 5: Federal Court
You have the right to continue your appeal by asking a Federal Court Judge to review
your case if the amount involved meets the minimum requirement specified in the Medicare Appeals Council's decision, you received a decision from the Medicare Appeals Council (Appeal Level 4), and:
- The decision is not completely favorable to you, or
- The decision tells you that the MAC decided not to review your appeal request.
How to file your appeal?
In order to request judicial review of your case, you must file a civil action in a United
States district court within sixty (60) calendar days after the date you were notified of the
decision made by the Medicare Appeals Council (Appeal Level 4). The letter you get
from the Medicare Appeals Council will tell you how to request this review, including
who can file the appeal.
Your appeal request will not be reviewed by a Federal Court if the dollar value of the
requested Part C medical care or service does not meet the minimum requirement
specified in the MAC’s decision.
How soon will the Court make a decision?
The Federal Court Judge will first decide whether to review your case. If it reviews your
case, a decision will be made according to the rules established by the Federal
judiciary.
If the Court decides against you
You may have further appeal rights in the Federal Courts.
Favorable Decisions by the ALJ, MAC, or a Federal Court Judge
This section explains what we must do if our initial decision denying what you asked for
is reversed by the ALJ, MAC, or a Federal Court Judge.
- For a decision about Part C medical care or services, we must pay for, authorize, or
provide the medical care or service you have asked for within sixty (60) days of the
date we receive the decision.
- For a decision to pay you back for a Part D drug you already paid for and received,
we must send payment to you within thirty (30) calendar days from the date we
receive notice reversing our decision.
- For a standard decision about a Part D drug you have not yet received, we must
cover the Part D drug you asked for within seventy-two (72) hours after we receive
notice reversing our decision.
- For a fast decision about a Part D drug you have not yet received, we must cover
the Part D drug you asked for within twenty-four (24) hours after we receive notice
reversing our decision.
Evidence of Coverage
For more detailed information and a description of the processes, refer to your Evidence
of Coverage.
Obtaining general information or information about the number of Appeals,
Grievances and/or Exceptions filed with Mercy MedicareADVANTAGE?
Mercy MedicareADVANTAGE HMO/PPO
Customer Contact Center
14528 S. Outer 40, Ste. 300
Chesterfield, MO 63017
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