CALIFORNIA - Pacificare Health Systems

PART B
n
n
Discontinuation of services you believe are
Medically Necessary Covered Services
Failure of PacifiCare to approve, furnish,
arrange for or provide payment for health
care services in a timely manner or to
provide you with a timely notice of an
adverse determination such that a delay
would adversely affect your health
Use the Appeal procedure when you want a
reconsideration of a decision (organizational
determination) that was made regarding a
service or the amount of payment PacifiCare
paid for a service.
Use the Grievance procedure for any
complaints or other disputes that are not
denied claims or denied services subject to
organization determinations as explained
above. If you have a question about which
complaint process to use, please call
Customer Service.
PacifiCare is required to track all Appeals
and Grievances in order to report cumulative
data to CMS and to Secure Horizons Group
Retiree Medicare Advantage Plan Members
upon request.
Who May File an Appeal
1. You may file an Appeal.
Section 9 – Organization Determination,
Appeals and Grievance Procedures
2. Someone else may file the Appeal for
you on your behalf. You may appoint an
individual to act as your representative to
file the Appeal for you by following the
steps below:
a. Provide PacifiCare with your name,
your Medicare number and a statement
which appoints an individual as
your representative. (Note: you may
appoint a physician or a Provider.) For
example: “ I __[your name]__ appoint
__[name of representative]__ to act
as my representative in requesting an
Appeal from PacifiCare and/or CMS
regarding the denial or discontinuation
of medical services.
b. You must sign and date the statement.
c. Your representative must also sign and
date this statement unless he or she is
an attorney.
d. You must include this signed statement
with your Appeal.
3. A Non-Contracted Medical Provider may
file a standard Appeal of a denied claim if
he or she completes a waiver of payment
statement which says he or she will not
bill you regardless of the outcome of the
Appeal.
Support for Your Appeal
You are not required to submit additional
information to support your request for
reconsideration (Appeal). PacifiCare is
responsible for gathering all necessary
medical information. However, it may be
helpful to include additional information to
clarify or support your request. For example,
you may want to include in your Appeal
request information such as medical records
or physician opinions in support of your
request. To obtain medical records, you may
send a written request to your Primary Care
Physician. If your medical records from a
Specialist are not included in your medical
records from your Primary Care Physician,
you may need to submit a separate request to
the Specialist who provided medical services
to you.
Assistance With an Appeal
Regardless whether you request a standard
or expedited Appeal, you can have a friend,
lawyer or someone else help you. There are
lawyers who do not charge unless you win
your Appeal. Groups such as lawyer referral
services can help you find a lawyer. There are
also groups, such as legal aid services, who
will provide free legal services if you qualify.
Standard Appeal Procedures
If you decide to proceed with the Medicare
Standard Appeals Procedure, the following
steps will occur:
Questions? Call the Customer Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
193
PART B