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) � 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. (For more information about the process for making complaints, including fast complaints, see Section 10 of this chapter.) � If we do not give you an answer by the deadline above (or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization. Later in this section, we tell about this review organization and explain what happens at Level 2 of the appeals process. • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal. • If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal. Step 3: If our plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process. • To make sure we were following all the rules when we said no to your appeal, we are required to send your appeal to the “Independent Review Organization.” When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2. Section 5.4 Step-by-step: How to make a Level 2 Appeal If we say no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your fi rst appeal. Th is organization decides whether the decision we made should be changed. Legal Terms Th e formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” Step 1: The Independent Review Organization reviews your appeal. • Th e Independent Review Organization is an independent organization that is hired by Medicare. Th is organization is not connected with us and it is not a government agency. Th is organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work. • We will send the information about your appeal to this organization. Th is information is called your “case fi le.” You have the right to ask us for a copy of your case fi le. We are allowed to charge you a fee for copying and sending this information to you. • You have a right to give the Independent Review Organization additional information to support your appeal. 157
158 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. If you had a “fast” appeal at Level 1, you will also have a “fast” appeal at Level 2 • If you had a fast appeal to our plan at Level 1, you will automatically receive a fast appeal at Level 2. Th e review organization must give you an answer to your Level 2 Appeal within 72 hours of when it receives your appeal. • However, if the Independent Review Organization needs to gather more information that may benefi t you, it can take up to 14 more calendar days. If you had a “standard” appeal at Level 1, you will also have a “standard” appeal at Level 2 • If you had a standard appeal to our plan at Level 1, you will automatically receive a standard appeal at Level 2. Th e review organization must give you an answer to your Level 2 Appeal within 30 calendar days of when it receives your appeal. • However, if the Independent Review Organization needs to gather more information that may benefi t you, it can take up to 14 more calendar days. Step 2: The Independent Review Organization gives you their answer. Th e Independent Review Organization will tell you its decision in writing and explain the reasons for it. • If the review organization says yes to part or all of what you requested, we must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we receive the decision from the review organization. • If this organization says no to part or all of your appeal, it means they agree with us that your request (or part of your request) for coverage for medical care should not be approved. (Th is is called “upholding the decision.” It is also called “turning down your appeal.”) � Th e written notice you get from the Independent Review Organization will tell you the dollar amount that must be in dispute to continue with the appeals process. For example, to continue and make another appeal at Level 3, the dollar value of the medical care coverage you are requesting must meet a certain minimum. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal, which means that the decision at Level 2 is fi nal. Step 3: If your case meets the requirements, you choose whether you want to take your appeal further. • Th ere are three additional levels in the appeals process after Level 2 (for a total of fi ve levels of appeal). • If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. Th e details on how to do this are in the written notice you got after your Level 2 Appeal.
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