CALIFORNIA - Pacificare Health Systems

PART B
194
Section 9 – Organization Determination,
Appeals and Grievance Procedures
1. You must submit a written request for a
reconsideration to the PacifiCare Appeals
and Grievance Unit at 5757 Plaza Drive,
Cypress, CA 90630. You may also request
a reconsideration through the Social
Security office. You must submit your
written request within sixty (60) calendar
days of the date of the notice of the initial
organization determination.
Note: The sixty (60)-day limit may be
extended for good cause. Include in your
written request the reason why you could
not file within the sixty (60)-day time
frame.
2. PacifiCare will conduct a reconsideration
and notify you in writing of the decision
within thirty (30) days, if the Appeal is
for a request for a denied service. Note
that PacifiCare must notify you of the
reconsideration decision as expeditiously
as possible, but no later than thirty
(30) calendar days from receipt of your
request. PacifiCare may extend this time
frame by up to fourteen (14) calendar
days if you request the extension or if
PacifiCare finds that additional information
is needed and the extension of time
benefits you (for example, if PacifiCare
needs additional medical records from
Non-Contracted Medical Providers that
could change a denial decision).
If the Appeal is for a denied claim,
PacifiCare must notify you of the
reconsideration determination no later
than sixty (60) days after receiving
your request for a reconsideration
determination.
PacifiCare’s reconsideration decision will
be made by a person(s) not involved
in the initial decision. A physician must
make all reconsiderations of adverse
organization determinations based on
Medical Necessity with expertise in the
field of medicine that is appropriate
for the service at issue. However, that
physician need not be of the same
specialty or subspecialty as the treating
physician.
3. If PacifiCare decides to reverse the
original adverse decision, PacifiCare
must authorize or arrange your service
as expeditiously as your health requires,
but no later than thirty (30) calendar days
from the date PacifiCare received your
request for an Appeal; or PacifiCare will
pay your claim within sixty (60) calendar
days of your request for an Appeal.
4. If PacifiCare decides to uphold the original
adverse decision, either in whole or in
part, or if PacifiCare fails to provide you
with a decision on your reconsideration
within the relevant time frame, PacifiCare
will automatically forward the case to
an Independent Review Entity for a new
and impartial review and you will be
notified. . PacifiCare must send the file
to the Independent Review Entity within
thirty (30) days of a request for services
and within sixty (60) days of a request for
payment. The Independent Review Entity
will either uphold PacifiCare’s decision
or issue a new decision. If PacifiCare
forwards the case to the Independent
Review Entity, PacifiCare still must notify
you of the decision within the relevant
time frame discussed above.
5. For cases submitted to an Independent
Review Entity for review, the Independent
Review Entity will make a reconsideration
decision and notify you in writing of their
decision and the reasons for the decision.
If the Independent Review Entity
decides in your favor and reverses
PacifiCare’s decision, the following
must occur:
n
Request for Service: If the
Independent Review Entity decides in
your favor, PacifiCare must authorize
the service under dispute within
seventy-two (72) hours from the date
of receipt of the Independent Review
Entity’s notice reversing PacifiCare’s
decision, or provide the service under
dispute as expeditiously as your health
condition requires, but no later than
fourteen (14) calendar days from date