5 - Complaints, Grievances & Appeals

5
COMPLAINTS,
GRIEVANCES & APPEALS
OVERVIEW
If a provider disagrees with any of Empire’s policies
or services, or would like to request a review of an
unfavorable determination, the provider may file a
complaint, grievance or appeal. Please refer to the
information below in order to follow the proper
procedures.
COMPLAINTS
A complaint is an expression of dissatisfaction with any
aspect of Empire’s healthcare services not involving a
plan decision. If a provider is dissatisfied with any
aspect of Empire’s policies or practices regarding the
delivery of services to covered persons, he or she may
file a complaint in writing to:
Empire
Provider Services Department
PO Box 1407
Church Street Station
New York, New York 10008-1407
Attn: Provider Services
Or file a complaint by phone at 1-800-552-6630
(No specific form for written complaints is required.)
The complaint and any supporting documentation
submitted by the provider will be investigated by a
qualified provider service representative. The results
will be communicated in a written decision to the
provider within 30 calendar days of receipt of all
necessary information.
This process applies to instances in which Empire is
not being asked to review or overturn a previous
administrative or medical management decision that
resulted in a claim denial, reduction in claim payment or
denial of precertification of covered services. The
processes used for those issues are described below.
GRIEVANCES
Grievances are requests to review unfavorable
decisions (also called adverse determinations) not
based on medical necessity (e.g., claim denial, benefit
limitation, subscriber contract exclusion, etc.).
Level One Grievances
You must file a level one grievance within
180 calendar days from the date of our initial
determination. Grievances filed after that date will
not be considered. To file a grievance, call or write
to Empire Provider Services at the address and
telephone number listed under complaints.
Empire will investigate and respond within 30 calendar
days of receipt of the grievance. In the case of an
urgent medical need where a delayed decision would
significantly increase the risk to a patient’s health,
Empire will render a decision faster. In this situation, the
provider can request an expedited grievance. Empire
will respond to expedited grievances within 72 hours of
receipt of the grievance.
Level Two Grievances
If providers are dissatisfied with Empire’s decision on a
level one grievance, they have 60 business days from
the date of the decision to file a level two grievance.
They can file by contacting Empire Provider Services at
the address and telephone number given at left.
Level two grievances will be reviewed by a
representative not involved with the previous adverse
determination. A decision will be reached within 30
calendar days of receipt of the grievance. Providers
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may also file expedited level two grievances. Empire
will respond to them within 72 hours of receipt of the
grievance.
Below are time frames for Empire’s response to
grievances.
Standard
Expedited
Level One
Within 30 calendar
days from our
receipt of the
grievance.
Within 72 hours
from our receipt of
the grievance
RECONSIDERATIONS
AND APPEALS
If the Medical Management Department determines
that an admission, extension of the hospital stay, or
some other healthcare service is not medically
necessary, you may request reconsideration (through
the attending physician) or appeal the decision in the
ways described in the following sections.
Reconsiderations
A request for reconsideration can be made by calling
or writing to the Medical Management Department,
the specific contact information for which will be
listed on the denial letter. The hospital or the
physician who recommended the admission, the
extension of a stay, or other healthcare services can
make the request for reconsideration. In addition,
the request can be made only:
If we deny service prior to or during a member’s
medical service, and
If the denial is based on issues of medical
necessity, and
If the decision occurred without our Medical Director
discussing the hospitalization or other services with
the physician who recommended them.
Services that have already been provided
are not subject to reconsideration.
Level Two
Within 30 calendar
days from our
receipt of the
grievance.
Within 72 hours
from our receipt of
the grievance
A reconsideration may be filed within seven
calendar days of our initial pre-service (prospective)
determination by contacting the Case Management
Department which rendered the initial denial of
service.
All reconsideration requests that are received
beyond seven calendar days of the initial pre-service
denial should be addressed to the Appeals Unit and
will be processed as appeals.
A request for reconsideration will be reviewed within
one business day by the Medical Director who made the
initial decision to deny the precertification or the
extension of service. The review will include any
additional information provided. If the Medical Director
who made the initial decision is not available, another
Medical Director may act in his or her place.
If we uphold our prior decision, written notification will
be provided. This notification will include the following:
The reasons for the decision, including the clinical
rationale
Information on how to obtain a copy of the clinical
review criteria used in making the decision
Instructions on how to initiate an appeal
What additional information, if any, must be
provided to or obtained by us in order to make a
decision on appeal
Appeals
Appeals are requests to review and change unfavorable
clinical decisions (also called adverse determinations)
such as when an admission, the extension of a stay or
some other healthcare service is determined not to be
medically necessary.
Expedited Appeals
A provider, a patient, a patient’s family or representative,
or a hospital may request an urgent/expedited appeal
when the denial of coverage involves:
Cases involving continued or extended healthcare
services
Requests for additional services for a patient
undergoing a continuing course of treatment
Cases in which the member’s physician or healthcare
provider believes an immediate appeal is warranted
An expedited appeal must be filed within 180 calendar
days of the initial unfavorable decision. Appeals filed
after that date will not be considered, and you will
receive a letter stating that the opportunity to file an
appeal has been exhausted.
Expedited appeals will be responded to within 72 hours
of Empire’s receipt of the necessary information.
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For our Administrative Service Only (ASO) line of
business, there are no further appeal options after
an expedited appeal.
For our fully insured lines of business, a level two
pre-service or post-service appeal may be filed
within 60 business days of a level one expedited
denial. Any level two appeals completed after an
expedited appeal will be responded to within
60 calendar days.
We will provide reasonable access to a Medical
Director within one business day of receiving notice
of the request for an expedited appeal.
Pre-Service (Prospective) Appeals
A pre-service appeal is a request to review an
unfavorable decision issued prior to or during a service.
Empire offers two levels of pre-service appeals for
providers:
Level one pre-service appeals must be filed
within 180 calendar days of the initial adverse
determination. Appeals filed after that date will not
be considered, and you will receive a letter stating
that the opportunity to file an appeal has been
exhausted. Level one pre-service appeals will be
responded to within 15 calendar days of Empire’s
receipt of the appeal request.
Level two pre-service appeals must be filed
within 60 business days of the level one appeal
determination. Appeals filed after that date will
not be considered, and you will receive a letter
stating that the opportunity to appeal has been
exhausted. Level two pre-service appeals will be
responded to within 15 calendar days of Empire’s
receipt of the appeal request.
Post-Service (Retrospective) Appeals
A post-service appeal is a request to review an
unfavorable decision issued after a service was
rendered. Empire offers two levels of post-service
appeals for providers:
Level one post-service appeals must be filed
within 180 calendar days of the initial adverse
determination. Appeals filed after that date will not
be considered, and you will receive a letter stating
that the opportunity to appeal has been exhausted.
Level one post-service appeals will be responded to
within 30 calendar days of Empire’s receipt of the
appeal request.
Level two post-service appeals must be filed
within 60 business days of the level one appeal
determination. Appeals filed after that date will not
be considered, and you will receive a letter stating
that the opportunity to appeal has been exhausted.
Level two post-service appeals will be responded to
within 30 calendar days of Empire’s receipt of the
appeal request.
Below are appeal time frames for fully insured and ASO
lines of business:
Standard
Expedited
Level One
Pre-Service
Within 15 calendar
days from the
receipt of the
appeal request.
Post-Service
Within 30 calendar
days from the
receipt of the
appeal request.
Within 72 hours
from the receipt of
the appeal request.
APPEAL REVIEW PROCESS
Level Two
Your appeal should be accompanied by a letter stating
why the decision is being appealed and why you feel
the decision should be overturned. Also include the
information necessary to review it, such as the
medical record.
All appeals are reviewed by a qualified medical
professional, with the same or similar specialty
as the practitioner rendering the care and who
was not involved with the initial determination.
Pre-Service
Within 15 calendar
days from the
receipt of the
appeal request.
Post-Service
Within 30 calendar
days from the
receipt of the
appeal request.
N/A for ASO
accounts. Within
60 calendar days
for fully insured
accounts.
If sufficient documentation to support the reasons for
the appeal is not provided, Empire Appeals Department
will attempt to request additional documentation or
medical records.
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Appeal Communication
If we make a decision favorable to the person filing the
appeal, written notification is sent stating that the denial
decision has been reversed. On the other hand, if we
make a decision that is not favorable, we will provide
written notification that will include the clinical
rationale upon which the appeal determination is
based. The letter will also contain information and rights
regarding any further appeals.
Expedited and pre-service appeal outcomes are also
telephonically relayed to the person filing the appeal.
External Appeals
Based on New York State Department of Insurance
regulations, if services were denied based on medical
necessity or a determination that they are experimental
or investigational, subsequent to an appeal you may
have the right to an external review. You can initiate an
external review using the form Empire will send you
when our final adverse determination is made. Please
note: providers may request external review only when
representing a member on pre-service (prospective)
appeal or themselves on a post-service (retrospective)
appeal.
BEHAVIORAL HEALTHCARE
APPEALS
To request an appeal of an initial behavioral
healthcare medical management decision (level one
determination) rendered by Magellan, please submit
your request in writing to:
Appeals Department
Magellan Behavioral Health
199 Pomeroy Road
Parsippany, NJ 07054
Should a member not be satisfied with the level one
determination, please follow the procedure outlined in
the level-one determination letter.
Send behavioral health related complaints or
grievances not relating to Medical Management
Department appeals to:
Complaints
Magellan Behavioral Health
199 Pomeroy Road
Parsippany, NJ 07054
Or call 1-800-626-3643
For all other behavioral health vendors, please follow
the instructions on the notice of adverse determination.
For information regarding all claims, or claim disputes,
call Empire Provider Services at 1-800-992-BLUE
(1-800-992-2583), Monday – Friday, 8:30 a.m. – 5:00 p.m.
OUR ADDITIONAL
RESPONSIBILITIES
In addition to the previously stated responsibilities,
we will also:
Protect the confidentiality of all parties involved in
the complaint and appeals process
Allow a member to appoint a representative to act on
his/her behalf at any point during the grievance and
appeals process
Include information regarding the next available
level of appeal into all adverse responses to appeals
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