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 this organization says yes to your appeal, then we must reimburse you (pay you back) for our share of the costs of care you have received since the date when we said your coverage would end. We must also continue to cover the care 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 the decision our plan made to your fi rst appeal and will not change it. � 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. 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 of appeal after Level 2, for a total of fi ve levels of appeal. If reviewers say no to your Level 2 Appeal, you can choose whether to accept that decision or whether 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. SECTION 9 TAKING YOUR APPEAL TO LEVEL 3 AND BEYOND Section 9.1 Levels of Appeal 3, 4, and 5 for Medical Service Appeals Th is section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal, and both of your appeals have been turned down. If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. If the dollar value is high enough, the written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal. For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels. Level 3 Appeal A judge who works for the Federal government will review your appeal and give you an answer. Th is judge is called an “Administrative Law Judge.” • If the Administrative Law Judge says yes to your appeal, the appeals process may or may not be over - We will decide whether to appeal this decision to Level 4. Unlike a decision at Level 2 (Independent Review Organization), we have the right to appeal a Level 3 decision that is favorable to you. � If we decide not to appeal the decision, we must authorize or provide you with the service within 60 days after receiving the judge’s decision. 185
186 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) � If we decide to appeal the decision, we will send you a copy of the Level 4 Appeal request with any accompanying documents. We may wait for the Level 4 Appeal decision before authorizing or providing the service in dispute. • If the Administrative Law Judge says no to your appeal, the appeals process may or may not be over. Level 4 Appeal � If you decide to accept this decision that turns down your appeal, the appeals process is over. � If you do not want to accept the decision, you can continue to the next level of the review process. If the administrative law judge says no to your appeal, the notice you get will tell you what to do next if you choose to continue with your appeal. Th e Medicare Appeals Council will review your appeal and give you an answer. Th e Medicare Appeals Council works for the Federal government. • If the answer is yes, or if the Medicare Appeals Council denies our request to review a favorable Level 3 Appeal decision, the appeals process may or may not be over - We will decide whether to appeal this decision to Level 5. Unlike a decision at Level 2 (Independent Review Organization), we have the right to appeal a Level 4 decision that is favorable to you. � If we decide not to appeal the decision, we must authorize or provide you with the service within 60 days after receiving the Medicare Appeals Council’s decision. � If we decide to appeal the decision, we will let you know in writing. • If the answer is no or if the Medicare Appeals Council denies the review request, the appeals process may or may not be over. � If you decide to accept this decision that turns down your appeal, the appeals process is over. If you do not want to accept the decision, you might be able to continue to the next level of the review process. If the Medicare Appeals Council says no to your appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 Appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal. Level 5 Appeal A judge at the Federal District Court will review your appeal. • Th is is the last step of the administrative appeals process.
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Page 221: 55 Water Street, New York, New York
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PPO II - EmblemHealth

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