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) • You can call us at Customer Service (phone numbers are printed on the back cover of this booklet). • To get free help from an independent organization that is not connected with our plan, contact your State Health Insurance Assistance Program (see Section 2 of this chapter). • For Part D prescription drugs, your doctor or other prescriber can request a coverage determination or a Level 1 or 2 appeal on your behalf. To request any appeal after Level 2, your doctor or other prescriber must be appointed as your representative. • For medical care, a doctor can make a request for you. Your doctor can request a coverage decision or a Level 1 appeal on your behalf. If your appeal is denied at Level 1, it will be automatically forwarded to Level 2. To request any appeal after Level 2, your doctor must be appointed as your representative. � Th ere may be someone who is already legally authorized to act as your representative under State law. � If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Customer Service (phone numbers are printed on the back cover of this booklet) and ask for the “Appointment of Representative” form. (Th e form is also available on Medicare’s website at http://www.cms.hhs.gov/cmsforms/downloads/ cms1696.pdf or on our website at www.emblemhealth.com/medicare.) Th e form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form. • You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. Th ere are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision. Section 4.3 Which section of this chapter gives the details for your situation? Th ere are four diff erent types of situations that involve coverage decisions and appeals. Since each situation has diff erent rules and deadlines, we give the details for each one in a separate section: • Section 5 of this chapter: “Your medical care: How to ask for a coverage decision or make an appeal” • Section 6 of this chapter: “Your Part D prescription drugs: How to ask for a coverage decision or make an appeal” • Section 7 of this chapter: “How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon” • Section 8 of this chapter: “How to ask us to keep covering certain medical services if you think your coverage is ending too soon” (Applies to these services only: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services) 149
150 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) IIf you’re not sure which section you should be using, please call Customer Service (phone numbers are printed on the back cover of this booklet). You can also get help or information from government organizations such as your State Health Insurance Assistance Program (Chapter 2, Section 3, of this booklet has the phone numbers for this program). SECTION 5 YOUR MEDICAL CARE: HOW TO ASK FOR A COVERAGE DECISION OR MAKE AN APPEAL ? Have you read Section 4 of this chapter (A guide to “the basics” of coverage decisions and appeals)? If not, you may want to read it before you start this section. Section 5.1 This 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 Th is section is about your benefi ts for medical care and services (but does not cover Part D drugs, please see Section 6 for Part D drug appeals). Th ese benefi ts are described in Chapter 4 of this booklet: Medical Benefi ts Chart (what is covered and what you pay). To keep things simple, we generally refer to “medical care coverage” or “medical care” in the rest of this section, instead of repeating “medical care or treatment or services” every time. Th is section tells what you can do if you are in any of the fi ve following situations: 1. You are not getting certain medical care you want, and you believe that this care is covered by our plan. 2. Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan. 3. You have received medical care or services that you believe should be covered by the plan, but we have said we will not pay for this care. 4. You have received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care. 5. You are being told that coverage for certain medical care you have been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health. • NOTE: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services, you need to read a separate section of this chapter because special rules apply to these types of care. Here’s what to read in those situations:
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:
Page 101 and 102:
Page 103 and 104: 98 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 153: 148 2013 Evidence of Coverage for P
Page 205 and 206:
200 2013 Evidence of Coverage for P
Page 207 and 208:
Page 209 and 210:
204 2011 Evidence of Coverage for H
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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?