Care Improvement Plus! This provider manual

line, or going online at www.careimprovementplus.com.
Provider Terminations
While Care Improvement Plus does not require members to be assigned to a Primary Care Physician
(PCP), when known, we will notify affected members thirty (30) days before the effective date of a
Primary Care Physician termination. The notification will include information that will assist the
member in selecting a new PCP, if requested. It will also identify resources for additional physician
selection assistance. Reasons for terminations will remain confidential.
Grievance Procedures
The purpose of the member grievance process is to provide a mechanism by which a Care Improvement
Plus member who is dissatisfied with any aspect of the health plan may file a formal grievance and have
the complaint investigated. A grievance is any complaint other than an adverse decision with regard to a
service or claim (e.g., denied authorizations and denied claims are appeals, not grievances). Timeframes
for responding to grievances are as follows:
• Thirty (30) days for regular grievance, but may extend fourteen (14) calendar days if additional
information is required
• Twenty-four (24) hours for an expedited grievance
Member Appeals
Members or their authorized representatives may request in writing an appeal of a denied service, such as
a disapproved authorization or admission, or a denied claim. The member has sixty (60) days from the
date of the denial to file an appeal. Care Improvement Plus conducts these reconsiderations, or first level
appeals, according to Medicare Advantage and Medicare Part D requirements. There are standard
timeframes for medical appeals and claims appeals. There also are expedited appeals for medical
services. The timeframes are as follows:
• Standard medical reconsiderations: Up to thirty (30) calendar days, with a possible extension of
fourteen (14) calendar days
• Expedited reconsiderations: seventy-two (72) hours or less based on need, with a possible
extension of fourteen (14) calendar days
• Medical claim reconsiderations: No more than sixty (60) days
With the prescription drug benefit, there are also appeals, or “redeterminations.” Appeals related to the
drug benefit may occur when a formulary drug is denied, a member’s drug claim is denied, a request for
an exception to the tiering structure of the formulary is rejected, a request for an exception to a drug
utilization management tool is rejected, or a request for a non-formulary drug is denied (See Section I:
Pharmacy Services). As with medical services, there are expedited appeals in addition to the standard
timeframes:
• Standard drug redeterminations: Up to seven (7) days
• Expedited drug redeterminations: Seventy-two (72) hours or less
There are several sources of information on how an enrollee may file an appeal, such as in their
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