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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) Legal Terms Th e formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” Step 1: We will automatically forward your case to the Independent Review Organization. • We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your fi rst appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. Th e complaint process is diff erent from the appeal process. Section 10 of this chapter tells how to make a complaint.) Step 2: The Independent Review Organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours. • Th e Independent Review Organization is an independent organization that is hired by Medicare. Th is organization is not connected with our plan 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. • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal of your hospital discharge. • If this organization says yes to your appeal, then we must reimburse you (pay you back) for our share of the costs of hospital care you have received since the date of your planned discharge. We must also continue the plan’s coverage of your inpatient hospital services for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services. • If this organization says no to your appeal, it means they agree with us that your planned hospital discharge date was medically appropriate. � Th e notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal, which is handled by a judge. Step 3: If the Independent Review Organization turns down your appeal, 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 reviewers say no to your Level 2 Appeal, you decide whether to accept their decision or go on to Level 3 and make a third appeal. • Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process 177
178 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) SECTION 8 How to ask us to keep covering certain medical services if you think your coverage is ending too soon Section 8.1 This section is about three services only: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services Th is section is about the following types of care only: • Home health care services you are getting. • Skilled nursing care you are getting as a patient in a skilled nursing facility. (To learn about requirements for being considered a “skilled nursing facility,” see Chapter 12, Defi nitions of important words.) • Rehabilitation care you are getting as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are getting treatment for an illness or accident, or you are recovering from a major operation. (For more information about this type of facility, see Chapter 12, Defi nitions of important words.) When you are getting any of these types of care, you have the right to keep getting your covered services for that type of care for as long as the care is needed to diagnose and treat your illness or injury. For more information on your covered services, including your share of the cost and any limitations to coverage that may apply, see Chapter 4 of this booklet: Medical Benefi ts Chart (what is covered and what you pay). When we decide it is time to stop covering any of the three types of care for you, we are required to tell you in advance. When your coverage for that care ends, we will stop paying our share of the cost for your care. If you think we are ending the coverage of your care too soon, you can appeal our decision. Th is section tells you how to ask for an appeal.
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PPO II - EmblemHealth

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