PPO II - EmblemHealth

More documents

Recommendations

Info

2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) BACKGROUND SECTION 1 INTRODUCTION Section 1.1 What to do if you have a problem or concern Th is chapter explains two types of processes for handling problems and concerns: • For some types of problems, you need to use the process for coverage decisions and making appeals. • For other types of problems, you need to use the process for making complaints. Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. Which one do you use? Th at depends on the type of problem you are having. Th e guide in Section 3 will help you identify the right process to use. Section 1.2 What about the legal terms? Th ere are technical legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to understand. To keep things simple, this chapter explains the legal rules and procedures using simpler words in place of certain legal terms. For example, this chapter generally says “making a complaint” rather than “fi ling a grievance,” “coverage decision” rather than “organization determination” or “coverage determination,” and “Independent Review Organization” instead of “Independent Review Entity.” It also uses abbreviations as little as possible. However, it can be helpful – and sometimes quite important – for you to know the correct legal terms for the situation you are in. Knowing which terms to use will help you communicate more clearly and accurately when you are dealing with your problem and get the right help or information for your situation. To help you know which terms to use, we include legal terms when we give the details for handling specifi c types of situations. SECTION 2 YOU CAN GET HELP FROM GOVERNMENT ORGANIZATIONS THAT ARE NOT CONNECTED WITH US Section 2.1 Where to get more information and personalized assistance Sometimes it can be confusing to start or follow through the process for dealing with a problem. Th is can be especially true if you do not feel well or have limited energy. Other times, you may not have the knowledge you need to take the next step. 145
146 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Get help from an independent government organization We are always available to help you. But in some situations you may also want help or guidance from someone who is not connected with us. You can always contact your State Health Insurance Assistance Program (SHIP). Th is government program has trained counselors in every state. Th e program is not connected with us or with any insurance company or health plan. Th e counselors at this program can help you understand which process you should use to handle a problem you are having. Th ey can also answer your questions, give you more information, and off er guidance on what to do. Th e services of SHIP counselors are free. You will fi nd phone numbers in Chapter 2, Section 3 of this booklet. You can also get help and information from Medicare For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare: • You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. • You can visit the Medicare website (http://www.medicare.gov).
Page 1 and 2:
H5528_123133 EVIDENCE OF COVERAGE Y
Page 3 and 4:
ii 2013 Evidence of Coverage for PP
Page 5 and 6:
iv 2013 Evidence of Coverage for PP
Page 7 and 8:
2 2013 Evidence Evidence of Coverag
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
10 2013 Evidence Evidence of Covera
Page 17 and 18:
12 Th ese rules apply for employer
Page 19 and 20:
14 2013 Evidence of Coverage for PP
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
26 SECTION 5 SOCIAL SECURITY 2013 E
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
48 2011 Evidence of Coverage for 20
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
82 2011 Evidence of Coverage for HM
Page 89 and 90:
84 2011 Evidence of Coverage 2013 f
Page 91 and 92:
86 2013 Evidence of Cover age for P
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100: 94 2013 Evidence of Cover age for P
Page 105 and 106: 100 2013 Evidence of Cover age for
Page 107 and 108: 102 2013 Evidence of Coverage for P
Page 109 and 110: 104 • Chapter 5 of this booklet.
Page 113 and 114: 108 Your share of the cost when you
Page 117 and 118: 112 These payments are not included
Page 119 and 120: 114 � Some vaccines are considere
Page 125 and 126: 120 2011 Evidence of Coverage for 2
Page 127 and 128: 122 2011 Evidence of Coverage for H
Page 149: 144 2013 Evidence of Coverage for P
Page 201 and 202:
196 2011 Evidence of Coverage for H
Page 203 and 204:
198 2013 Evidence of Coverage for P
Page 205 and 206:
Page 207 and 208:
Page 209 and 210:
Page 211 and 212:
Page 213 and 214:
Page 215 and 216:
Page 217 and 218:
Page 219 and 220:
Page 221:
55 Water Street, New York, New York
show all

PPO II - EmblemHealth

Create successful ePaper yourself

Delete template?

Save as template?