PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) BACKGROUND SECTION 1 Introduction ......................................................................................... 145 Section 1.1 What to do if you have a problem or concern ..........................................................145 Section 1.2 What about the legal terms? .....................................................................................145 SECTION 2 You can get help from government organizations that are not connected with us ......................................................... 145 Section 2.1 Where to get more information and personalized assistance .....................................145 SECTION 3 To deal with your problem, which process should you use? .........147 Section 3.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints? .........................................147 COVERAGE DECISIONS AND APPEALS SECTION 4 A guide to the basics of coverage decisions and appeals ........... 148 Section 4.1 Asking for coverage decisions and making appeals: the big picture ...........................148 Section 4.2 How to get help when you are asking for a coverage decision or making an appeal ...148 Section 4.3 Which section of this chapter gives the details for your situation? ............................149 SECTION 5 Your medical care: How to ask for a coverage decision or make an appeal .............................................................................. 150 Section 5.1 Th is section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for our share of the cost of your care ..........150 Section 5.2 Step-by-step: How to ask for a coverage decision (how to ask our plan to authorize or provide the medical care coverage you want) .................................151 Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a medical care coverage decision made by our plan) ..........................................154 Section 5.4 Step-by-step: How to make a Level 2 Appeal ............................................................157 Section 5.5 What if you are asking us to pay you for our share of a bill you have received for medical care? ..............................................................................159 141
142 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) SSECTION 6 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal ............................................. 160 Section 6.1 Th is section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug .........................................160 Section 6.2 What is an exception? ..............................................................................................161 Section 6.3 Important things to know about asking for exceptions .............................................163 Section 6.4 Step-by-step: How to ask for a coverage decision, including an exception .................163 Section 6.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a coverage decision made by our plan) ..............................................................166 Section 6.6 Step-by-step: How to make a Level 2 Appeal ............................................................168 SECTION 7 How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon ..................... 170 Section 7.1 During your inpatient hospital stay, you will get a written notice from Medicare that tells about your rights .....................................................................171 Section 7.2 Step-by-step: How to make a Level 1 Appeal to change your hospital discharge date ..........................................................................................172 Section 7.3 Step-by-step: How to make a Level 2 Appeal to change your hospital discharge date ..........................................................................................174 Section 7.4 What if you miss the deadline for making your Level 1 Appeal? ...............................175 SECTION 8 How to ask us to keep covering certain medical services if you think your coverage is ending too soon ................................178 Section 8.1 Th is section is about three services only: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services .......................................................................................178 Section 8.2 We will tell you in advance when your coverage will be ending ................................179 Section 8.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover your care for a longer time ...........................................................................179 Section 8.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover your care for a longer time ...........................................................................181 Section 8.5 What if you miss the deadline for making your Level 1 Appeal? ...............................183
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PPO II - EmblemHealth

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