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) SECTION 3 TO DEAL WITH YOUR PROBLEM, WHICH PROCESS SHOULD YOU USE? Section 3.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints? If you have a problem or concern, you only need to read the parts of this chapter that apply to your situation. Th e guide that follows will help. To fi gure out which part of this chapter will help with your problem or concern START HERE Is your problem or concern about your benefi ts and coverage? (This includes problems about whether particular medical care or prescription drugs are covered or not, the way in which they are covered, and problems related to payment for medical care or prescription drugs.) My problem is about benefi ts or coverage Yes Go to the next section of this chapter, Section 4, “A guide to the basics of coverage decisions and making appeals.” No My problem is not about benefi ts or coverage Skip ahead to Section 10 at the end of this chapter, “How to make a complaint about quality of care, waiting times, customer service or other concerns.” 147
148 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) COVERAGE DECISIONS AND APPEALS SECTION 4 A GUIDE TO THE BASICS OF COVERAGE DECISIONS AND APPEALS Section 4.1 Asking for coverage decisions and making appeals: the big picture Th e process for coverage decisions and making appeals deals with problems related to your benefi ts and coverage for medical services and prescription drugs, including problems related to payment. Th is is the process you use for issues such as whether something is covered or not and the way in which something is covered. Asking for coverage decisions A coverage decision is a decision we make about your benefi ts and coverage or about the amount we will pay for your medical services or drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. Making an appeal If we make a coverage decision and you are not satisfi ed with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by diff erent reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision. If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. Th e Level 2 Appeal is conducted by an independent organization that is not connected to us. (In some situations, your case will be automatically sent to the independent organization for a Level 2 Appeal. If this happens, we will let you know. In other situations, you will need to ask for a Level 2 Appeal.) If you are not satisfi ed with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal. Section 4.2 How to get help when you are asking for a coverage decision or making an appeal Would you like some help? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:
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PPO II - EmblemHealth

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