2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appeals and GrievancesMember Appeals and GrievancesWith written consent from the member to act astheir representative during the appeal process,providers may appeal a denied benefit certificationor a concurrent review decision to denyauthorization that was made by the medicaldirector. At the time of the decision, a provider ormember may request that Presbyterian reconsiderthe denial by submitting further documentation tosupport medical necessity. Such requests arereferred immediately to a medical director notpreviously involved in the case for resolution andare handled according to the member appealguidelines.If benefit certification or prior authorization forservices for any Presbyterian member is requestedby a provider and denied by Presbyterian, aprovider may act on the member’s behalf and mayfile a request for an expedited appeal if the providerfeels that the member’s health or welfare are inimmediate jeopardy. Presbyterian then determinesif it meets expedited criteria. If the case is deemedexpedited, Presbyterian processes the expeditedappeal within 72 hours of receipt. (Time extensionsmay apply with written consent from the member.)For Presbyterian Centennial Care, unless themember or the provider requests an expeditedresolution, an oral appeal must be followed by awritten appeal that is signed by the member within13 calendar days; failure to file the written appealwithin 13 calendar days constitutes withdrawal ofthe appeal.The Presbyterian member appeals and grievanceprocess is published in the member handbooks.Presbyterian provides a process that ensures allmembers have the right to exercise their right to anappeal and that they receive the decision within theappropriate and proper time frames for resolution oftheir appeals.Any member also has the right to file a grievance ifhe or she is dissatisfied with the services renderedthrough Presbyterian. In respect to grievances, themember is defined as any individual enrolled inPresbyterian or their designated representative. Aprovider may represent a member in a grievance orappeal with written consent from the member.Member grievances may include but are not limitedto dissatisfaction with providers, appropriateness ofservices rendered, timeliness of services rendered,availability of services, delivery of services,reduction or termination of services, disenrollment,or any other performance that is consideredunsatisfactory. The member should submit agrievance to the Presbyterian grievance andappeals coordinator within 30 calendar days of thedate the dissatisfaction occurred.The member should submit an appeal to thegrievance and appeals coordinator within 90 daysfrom the date of denial.Member Fair HearingA member may request a State Fair Hearing if heor she is dissatisfied with an action that has beentaken by Presbyterian, and the member hasexhausted Presbyterian’s internal process, within30 calendar days of the Presbyterian’s finaldecision. A representative of the member or themember’s estate, or a provider acting on behalf of20-32014 Practitioner and Provider Manual - Ver. 3