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) Legal Terms Th is notice explanation is called the “Detailed Explanation of Non-Coverage.” Step 3: Within one full day after they have all the information they need, the reviewers will tell you their decision. What happens if the reviewers say yes to your appeal? • If the reviewers say yes to your appeal, then we must keep providing your covered services for as long as it is medically necessary. • You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered services (see Chapter 4 of this booklet). What happens if the reviewers say no to your appeal? • If the reviewers say no to your appeal, then your coverage will end on the date we have told you. We will stop paying its share of the costs of this care. • If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will have to pay the full cost of this care yourself. Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal. • Th is fi rst appeal you make is “Level 1” of the appeals process. If reviewers say no to your Level 1 Appeal – and you choose to continue getting care after your coverage for the care has ended – then you can make another appeal. • Making another appeal means you are going on to “Level 2” of the appeals process. Section 8.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover your care for a longer time If the Quality Improvement Organization has turned down your appeal and you choose to continue getting care after your coverage for the care has ended, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your fi rst appeal. If we turn down your Level 2 Appeal, you may have to pay the full cost for your home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end. 181
182 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Here are the steps for Level 2 of the appeal process: Step 1: You contact the Quality Improvement Organization again and ask for another review. • You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation. • Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal. Step 3: Within 14 days, the Quality Improvement Organization reviewers will decide on your appeal and tell you their decision. What happens if the review organization says yes to your appeal? • We must reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. We must continue providing coverage for the care for as long as it is medically necessary. • You must continue to pay your share of the costs and there may be coverage limitations that apply. What happens if the review organization says no? • It means they agree with the decision we made to your Level 1 Appeal and will not change it. • Th e notice you get 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 the next level of appeal, which is handled by a judge. Step 4: If the answer is no, you will need to decide whether you want to take your appeal further. • Th ere are three additional levels of appeal after Level 2, for a total of fi ve levels of appeal. If reviewers turn down your Level 2 Appeal, you can choose whether to accept that decision or to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by a judge. • Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.
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PPO II - EmblemHealth

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