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, Section 7: How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon. � Chapter 9, Section 8: How to ask us to keep covering certain medical services if you think your coverage is ending too soon. Th is section is about three services only: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services. • For all other situations that involve being told that medical care you have been getting will be stopped, use this section (Section 5) as your guide for what to do. Which of these situations are you in? If you are in this situation: This is what you can do: Do you want to fi nd out whether our plan will cover the medical care or services you want? Has our plan already told you that we will not cover or pay for a medical service in the way that you want it to be covered or paid for? Do you want to ask our plan to pay you back for medical care or services you have already received and paid for? You can ask us to make a coverage decision for you. Go on to the next section of this chapter, Section 5.2 You can make an appeal. (Th is means you are asking us to reconsider.) Skip ahead to Section 5.3 of this chapter You can send us the bill. Skip ahead to Section 5.5 of this chapter 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) Legal Terms When a coverage decision involves your medical care, it is called an “organization determination.” Step 1: You ask our plan to make a coverage decision on the medical care you are requesting. If your health requires a quick response, you should ask us to make a “fast coverage decision.” 151
152 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Legal Terms A “fast coverage decision” is called an “expedited determination.” How to request coverage for the medical care you want • Start by calling, writing, or faxing our plan to make your request for us to provide coverage for the medical care you want. You, your doctor, or your representative can do this. • For the details on how to contact us, go to Chapter 2, Section 1 and look for the section called, How to contact us when you are asking for a coverage decision about your medical care. Generally we use the standard deadlines for giving you our decision When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard coverage decision means we will give you an answer within 14 days after we receive your request. • However, we can take up to 14 more calendar days if you ask for more time, or if we need information (such as medical records from out-of-network providers) that may benefi t you. If we decide to take extra days to make the decision, we will tell you in writing. • If you believe we should not take extra days, you can fi le a “fast complaint” about our decision to take extra days. When you fi le a fast complaint, we will give you an answer to your complaint within 24 hours. (Th e process for making a complaint is diff erent from the process for coverage decisions and appeals. For more information about the process for making complaints, including fast complaints, see Section 10 of this chapter.) If your health requires it, ask us to give you a “fast coverage decision” • A fast coverage decision means we will answer within 72 hours. � However, we can take up to 14 more calendar days if we fi nd that some information that may benefi t you is missing (such as medical records from out-of-network providers), or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing. � If you believe we should not take extra days, you can fi le a “fast complaint” about our decision to take extra days. (For more information about the process for making complaints, including fast complaints, see Section 10 of this chapter.) We will call you as soon as we make the decision. • To get a fast coverage decision, you must meet two requirements: � You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care you have already received.)
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PPO II - EmblemHealth

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