Grievances and Appeals

VNS Health EasyCare (HMO) and VNS Health EasyCare Plus (HMO D-SNP) Grievances and Appeals

If you have Medicare and get assistance from Medicaid, the information below applies to all of your Medicare and Medicaid benefits. You do not have to use one process for your Medicare benefits and a different process for your Medicaid benefits. This is sometimes called an “integrated process” because it integrates Medicare and Medicaid processes.

FILING AN ORGANIZATION DETERMINATION (ALSO KNOWN AS A “COVERAGE DECISION” OR AN “ACTION”)

An Organization Determination is when the plan, or a delegated vendor, has made a decision about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are called “coverage decisions.”   You, your representative, or any provider that furnishes, or intends to furnish, services to you may request an organization determination by filing a request with VNS Health Health Plans.

FILING A PART D EXCEPTION (WHICH IS ALSO A “COVERAGE DECISION” OR AN “ACTION”)

If a drug is not covered in the way you would like it to be covered, you can ask VNS Health Health Plans to make an “exception.”  An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:

• Covering a Part D drug for you that is not on our plan’s List of Covered Drugs (Formulary)
• Removing a restriction on the plan’s coverage for a covered drug
• Changing coverage of a drug to a lower cost-sharing tier

TIMEFRAMES FOR COVERAGE DECISIONS

• Standard Coverage Decision – Generally, on a request for a medical item or service, we will give you our answer within 14 calendar days after receiving your request. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours of receiving your request.
• For a Medical Item or Service – A Fast Coverage Decision is called an integrated expedited determination. A fast coverage decision means we will answer within 72 hours of your request for a medical item or service. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours.
• For a coverage decision about the drug(s) or payment – A Fast Coverage Decision is called an expedited coverage determination. We will give you an answer within 24 hours after we receive your doctor’s statement.
• Claim Coverage Determinations – Notification of a decision will be made within 30 calendar days of receipt if they are submitted by you, or on your behalf, or are claims that are not furnished under a written agreement between the plan and the provider. Claims from noncontracted providers must be paid or denied within 60 calendar days from the date of the request.

FILING AN APPEAL

If we say no to your coverage decision, you have the right to ask for an appeal. Asking for an appeal means asking us to reconsider — and possibly change — the decision we made. You may also ask for an appeal if you disagree with our decision to stop services that you are receiving. For example, you could file an appeal if:

• We refuse to cover or approve a service you think we should cover.
• We refuse to pay for a service that was provided to you and you think we should pay for the service.
• We reduce or cut back on a service you have been receiving.
• You think we are stopping your coverage for a service too soon.

TIMEFRAMES FOR APPEALS

You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Please include your reason in your appeal request.

Our timeframes to respond to your appeal are as follows:

• “Fast” Appeal: When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal; this includes “fast appeals” for Medicare Part B drugs. If you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we decide to take extra days to make the decision, we will tell you in writing. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug or a payment appeal.

• Standard Appeals: If we are using the standard deadlines, we must give you our answer on a request for a medical item or service within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. If your request is for a Medicare Part B prescription drug, we will give you our answer within 7 calendar days after we receive your appeal if your appeal is about coverage for a Part B prescription drug you have not yet received. We will give you our decision sooner if your health condition requires us to.

• If you ask for more time or if we need to gather more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we decide we need to take extra days to make the decision, we will tell you in writing. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug or a payment appeal.

• If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a “fast complaint,” we will give you an answer to your complaint within 24 hours.

• If we do not give you an answer by the applicable deadlines above (or by the end of the extended time we took on your request for a medical item or service), we are required to send your request on to Level 2 of the appeals process. Then an independent outside organization will review it. For more information, please refer to your Member Handbook or call your Care Team.

• Provider Claim Appeals: Please refer to the Claims, Billing, and Payments page.
  

FILING A COMPLAINT (ALSO KNOWN AS “FILING A GRIEVANCE”)

A complaint is a process our members can use for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. If your problem is related to benefits, coverage decisions, or payment, please refer to the coverage decision and appeal sections above. Some examples of problems that would follow the complaint process are:

• You are treated rudely by anyone connected with your care such as your doctors, pharmacy, other health care providers, or plan representatives.
• You are unable to reach someone by phone or get the information you need.
• You are unhappy with the quality of care you received from a doctor or health care facility such as a clinic or hospital.
• You have a problem with your doctor’s office, whether it is the condition or cleanliness of the doctor’s office, or you are kept too long in the waiting room.
• We took too long to answer your coverage decision request, or appeal.

For more information, see Common Questions about Filing an Appeal or Complaint, below.

TIMEFRAMES FOR FILING COMPLAINTS

Whether you call or write, you should contact us right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.  We recommend that you file your complaint as soon as you are able to and provide as much information as you can to help us understand your problem and help resolve it sooner.

Our timeframes to respond to complaints are:

• “Fast” Complaints: If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” or if we extended the timeframe of your coverage decision or appeal, we will automatically give you a “fast complaint”. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

• Standard Complaints: Notification of a decision will be given within 30 calendar days of receiving the written or oral complaint. VNS Health EasyCare or EasyCare Plus may extend the 30 calendar day timeframe by up to 14 calendar days if you or a provider on your behalf (written or oral) requests the extension or if VNS Health justifies a need for additional information because it is in your best interest. 

COMMON QUESTIONS ABOUT FILING A COVERAGE DECISION, APPEAL, OR COMPLAINT

Below are frequently asked questions about filing an appeal or complaint.