EXCEPTIONS & APPEALS

The following explain the process for coverage decisions and making appeals.  If you want to request a coverage decision or make an appeal related to benefits and coverage for medical services and prescription drugs, including problems related to payment, this guide will walk you through the process. 

For complete details on your medical and prescription drug coverage please refer to Chapter 7 of your Evidence of Coverage for MA only plans and Chapter 9 of your Evidence of Coverage for MA-PD plans. There is a complete section of the EOC devoted to the details of coverage decisions, appeals and exceptions.

Medicare Advantage Request for Part C Medical Appeal
For use when appealing the denial of a medical service or claim. Appeal requests must be made within 60 calendar days of the denial notification.

Medicare Advantage Request for Part D Prescription (RX) Appeal
For use when appealing the denial of a prescription drug preauthorization or claim. Appeal request must be made within 60 calendar days of the denial notification. Prescription Drug requests and appeals are handled through Express Scripts. 

If you have any questions or need Information on how to obtain an aggregate number of grievances, appeals, and exceptions filed with BlueShield of Northeastern New York, , please contact Member Services at 1-800-329-2792 (TTY 711) This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

We are available:

October 1 - February 14
8 a.m. to 8 p.m., 7 days a week

February 15 - September 30
8 a.m. to 8 p.m., Monday - Friday

During non-business hours, your call will be answered by our automated phone system. A Customer Service Representative will return your call on the next business day.

To file a complaint or appeal directly with Medicare, please visit: http://www.medicare.gov/claims-and-appeals/index.html or call 1-800-MEDICARE, 24 hours a day, 7 days a week.

Go to the Office of the Medicare Ombudsman

You are now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the link below

Visit Medicare.gov to submit your feedback

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You or your doctor can also contact the plan and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were being fair and following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision.  When we have completed the review we give you our decision.

If we say no to all or part of your Level 1 Appeal, your case will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to us. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.

This section tells what you can do if you are in any of the five following situations:  

  • You are not getting certain medical care you want, and you believe that this care is covered by our plan.
  • Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan.
  • You have received medical care or services that you believe should be covered by the plan, but we have said we will not pay for this care.
  • You have received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care.
  • You are being told that coverage for certain medical care you have been getting will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.

NOTE: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation (CORF) services, you need to read a separate section of Chapter 7 (MA only) or Chapter 9 (MA-PD) because special rules apply to these types of care. 

Step 1: You ask our plan to make a coverage decision on the medical care you are requesting. If your health requires a quick response, you should ask us to make a "fast decision".

  • Start by calling, writing, or faxing our plan to make your request for us to provide coverage for the medical care you want. You, or your doctor, or your representative* can do this.
  • Call Member Services at 1-866-346-6134 to initiate your coverage decision request. TTY users can call 1-866-346-6135; this number requires special telephone equipment and is only for people who have difficulties hearing or speaking.

Hours of Availability:

October 1 - February 14
8 a.m. to 8 p.m., 7 days a week

February 15 - September 30
8 a.m. to 8 p.m., Monday - Friday

During non-business hours, your call will be answered by our automated phone system.  A Customer Service Representative will return your call on the next business day.

Or Write to Us at:
PO Box 5201
Binghamton, NY 13902

Or Fax Us at:
1-803-264-9581

You can ask someone to act on your behalf.

If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.

  • There may be someone who is already legally authorized to act as your representative under State law.
  • If you want a friend, relative, your doctor or other provider, or other person to be your representative, you must complete an Appointment of Representation (Form CMS-1696). You can get a copy of the form here.
  • Or you can call Member Services and ask for the form to give that person permission to act on your behalf.
  • The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.

Generally we use the standard deadlines for giving you our decision:

When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 14 days after we receive your request.

  • However, we can take up to 14 more days if you ask for more time, or if we need information (such as medical records) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.
  • 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. (The process for making a complaint is different from the process for coverage decisions and appeals.  For more information about the process or making complaints, including fast complaints, see your Evidence of Coverage.)

 If your health requires it, ask us to give you a “fast decision”

  • A fast decision means we will answer within 72 hours.  
  • However, we can take up to 14 more calendar days if we find that some information may benefit you is missing (such as Medicare records or if you need time to get information to us for the review.  If we decide to take extra days, we will tell you in writing.
  • If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days

To get a fast decision, you must meet two requirements:

  • You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. ( You cannot get a fast coverage decision if your request is about payment for medical care you have already received.)
  • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function

If your doctor tells us that your health requires a "fast coverage decision" we will automatically agree to give you a fast coverage decision.

If your ask for a fast coverage decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision.

  • If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead)
  • This letter will tell you if your doctor asks for the fast coverage decision, we will automatically give you a fast coverage decision.
  • The letter will also tell how you can file a "fast complaint" about our decision to give you a standard coverage decision instead of the fast coverage decision you requested.

Step 2: We consider your request for medical care coverage and give you our answer.

Deadlines for a “fast” coverage decision

  • Generally, for a fast coverage decision, we will give you our answer within 72 hours.
  • As explained above, we can take up to 14 more     calendar days under certain circumstances. If we decide    to take extra days to make the coverage decision, we will  tell you in writing.
  • 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. (For more information about the process for making complaints, including fast complaints, see Section 9 of this chapter.)
  • If we do not give you our answer within 72 hours (or if there is an extended time period, by the end of that period), you have the right to appeal. Section 5.3 below tells how to make an appeal.

If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period.

If our answer is no to part or all of what you requested, we will send you a detailed written explanation as to why we said no.

Deadlines for a “standard” coverage decision

  • Generally, for a standard coverage decision, we will give you our answer within 14 days of receiving your request.
  • We can take up to 14 more calendar days (“an extended  time period”) under certain circumstances. If we decide to  take extra days to make the coverage decision, we will tell you in writing.
  • 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. (For more information  about the process for making complaints, including fast      complaints, see Section 9 of this chapter.)
  • If we do not give you our answer within 14 days (or if      there is an extended time period, by the end of that         period), you have the right to appeal. Section 5.3 below   tells how to make an appeal.

If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period.

If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal.

  • If we say no, you have the right to ask us to reconsider – and perhaps change – this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want.
  • If you decide to make an appeal, it means you are going on to Level 1 of the appeals process (see Section 5.3 below).

Step 1: You contact our plan and make your appeal. If your health requires a quick response, you must ask for a “fast appeal.”

To start an appeal you, your representative*, or in some cases your doctor must contact our plan.

Call Customer Service at 1-800-329-2792 to initiate your coverage decision request. TTY users can call TYY 711 (this number requires special telephone equipment and is only for people who have difficulties hearing or speaking).

Hours of Availability:

October 1 - February 14
8 a.m. to 8 p.m., 7 days a week

February 15 - September 30
8 a.m. to 8 p.m., Monday - Friday

During non-business hours, your call will be answered by our automated phone system. A Customer Service Representative will return your call on the next business day.

Or write to us at:

PO Box 5201
Binghamton, NY 13902

Or fax us at:

1-803-264-9581

*If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. (To get the form, call Customer Service and ask for the “Appointment of Representative” form. It is also available on Medicare‟s website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf). While we can accept an appeal request without the form, we cannot complete our review until we receive it. If we do not receive the form within 44 days after receiving your appeal request (our deadline for making a decision on your appeal), your appeal request will be sent to the Independent Review Organization for dismissal.

  • Make your standard appeal in writing by submitting a signed request.
  • 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. Examples of a good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with an incorrect or incomplete information about the deadline for requesting an appeal.
  • You can ask for a copy of the information in your appeal and add more information if you like.
    • You have the right to ask us for a copy of the information regarding your appeal. We are allowed to charge a fee for copying and sending this information to you.
    • If you wish, you and your doctor may give us additional information to support your appeal.

If your health requires it, ask for a “fast appeal” (you can make an oral request):

  • If you are appealing a decision our plan made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal.”
  • The requirements and procedures for getting a “fast appeal” are the same as those for getting a “fast decision.” To ask for a fast appeal, follow the instructions for asking for a fast decision. (These instructions are given earlier in this section.)
  • If your doctor tells us that your health requires a "fast appeal," we will automatically agree to give you a fast appeal.

Step 2: Our plan considers your appeal and we give you our answer.

  • When our plan is reviewing your appeal, we take another careful look at all of the information about your request for coverage of medical care. We check to see if we were being fair and following all the rules when we said no to your request.
  • We will gather more information if we need it. We may contact you or your doctor to get more information.

Deadlines for a “fast” appeal:

  • When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.
    • However, 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 days. If we decide to take extra days to make the decision, we will tell you in writing.
    • If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization.
  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal.
  • If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have sent your appeal to the Independent Review Organization for a Level 2 Appeal.

Deadlines for a “standard” appeal:

  • If we are using the standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. We will give you our decision sooner if your health condition requires us to.
    • However, 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 days
    • 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 deadline above (or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization. 
  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal.
  • If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have sent your appeal to the Independent Review Organization for a Level 2 Appeal.

Step 3: If our plan says no to your appeal, your case will automatically be sent on to the next level of the appeals process.

  • To make sure we were being fair when we said no to your appeal, our plan is required to send your appeal to the “Independent Review Organization.” When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2.

 

If our plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our plan made when we said no to your first appeal. This organization decides whether the decision we made should be changed.

Step 1: The Independent Review Organization reviews your appeal.

  • The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.
  • We will send the information about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file. We are allowed to charge you a fee for copying and sending this information to you.
  • You have a right to give the Independent Review Organization additional information to support your appeal.
  • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal.

If you had a “fast” appeal at Level 1, you will also have a “fast” appeal at Level 2:

  • If you had a fast appeal to our plan at Level 1 and requested a fast appeal at Level 2, the review organization must give you an answer to your Level 2 Appeal within 72 hours of when it receives your appeal.
  • However, if the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days.

If you had a “standard” appeal at Level 1, you will also have a “standard” appeal at Level 2:

  • If you made a standard appeal to our plan at Level 1 and requested a standard appeal at Level 2, the review organization must give you an answer to your Level 2 Appeal within 30 calendar days of when it receives your appeal.
  • However, if the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days.

Step 2: The Independent Review Organization gives you their answer.

The Independent Review Organization will tell you its decision in writing and explain the reasons for it.

  • If the review organization says yes to part or all of what you requested, we must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we receive the decision from the review organization.
  • If this organization says no to part or all of your appeal, it means they agree with us that your request (or part of your request) for coverage for medical care should not be approved. (This is called “upholding the decision.” It is also called “turning down your appeal.”)
  • The written notice you get from the Independent Review Organization will tell you the dollar value that must be in dispute to continue with the appeals process. For example, to continue and make another appeal at Level 3, the dollar value of the medical care coverage you are requesting must meet a certain minimum. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal, which means that the decision at Level 2 is final. The written notice you get from the Independent Review Organization will tell you how to find out the dollar amount to continue the appeals process.

Step 3: If your case meets the requirements, you choose whether you want to take your appeal further.

  • There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).
  • If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. The details on how to do this are in the written notice you got after your Level 2 Appeal.
  • The Level 3 Appeal is handled by an administrative law judge.

If you want to ask us for payment for medical care, start by reading Chapter 5 of this booklet: Asking us to pay our share of a bill you have received for covered medical services. Chapter 5 describes the situations in which you may need to ask for reimbursement or to pay a bill you have received from a provider. It also tells how to send us the paperwork that asks us for payment.

Asking for reimbursement is asking for a coverage decision from us

If you send us the paperwork that asks for reimbursement, you are asking us to make a coverage decision (for more information about coverage decisions, see Section 4.1 of this chapter). To make this coverage decision, we will check to see if the medical care you paid for is a covered service (see Chapter 4: Medical Benefits Chart (what is covered and what you pay)). We will also check to see if you followed all the rules for using your coverage for medical care (these rules are given in Chapter 3 of this booklet: Using the plan’s coverage for your medical services).

We will say yes or no to your request

  • If the medical care you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of your medical care within 60 calendar days after we receive your request. Or, if you haven’t paid for the services, we will send the payment directly to the provider. When we send the payment, it’s the same as saying yes to your request for a coverage decision.)
  • If the medical care is not covered, or you did not follow all the rules, we will not send payment. Instead, we will send you a letter that says we will not pay for the services and the reasons why in detail. (When we turn down your request for payment, it’s the same as saying no to your request for a coverage decision.)

What if you ask for payment and we say that we will not pay?

If you do not agree with our decision to turn you down, you can make an appeal. If you make an appeal, it means you are asking us to change the coverage decision we made when we turned down your request for payment.

To make this appeal, follow the process for appeals that we describe in part 5.3 of this section. Go to this part for step-by-step instructions. When you are following these instructions, please note:

  • If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we receive your appeal. (If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal.)
  • If the Independent Review Organization reverses our decision to deny payment, we must send the payment you have requested to you or to the provider within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process after Level 2, we must send the payment you requested to you or to the provider within 60 calendar days.

If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. You, your appointed representative, or your prescriber may use this form to request a redetermination (appeal) from your plan sponsor.

Step 1: You ask our plan to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a “fast decision.” You cannot ask for a fast decision if you are asking us to pay you back for a drug you already bought.

What to do:

  • Request the type of coverage decision you want. Start by writing, or faxing Express Scripts to make your request. You, your representative, or your doctor (or other prescriber) can do this.
  • You, your doctor, or someone else who is acting on your behalf can ask for a coverage decision. Chapter 9, Section 4 of your MA-PD Evidence of Coverage tells you how you can give written permission to someone else to act as your representative*. You can also have a lawyer act on your behalf.
  • If you want to ask us to pay you back for a drug, start by reading Chapter 7 of your MA-PD Evidence of Coverage: Asking us to pay our share of a bill you have received for covered medical services or drugs. Chapter 7 describes the situations in which you may need to ask for reimbursement. It also tells how to send us the paperwork that asks us to pay you back for our share of the cost of a drug you have paid for.
  • If you are requesting an exception, provide the “doctor’s statement.” Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. (We call this the “doctor’s statement.”) Your doctor or other prescriber can fax Express Scripts at 1-877-328-9799 or mail the statement to Express Scripts, Attn: Medicare Reviews, PO Box 66571, St. Louis, MO 63166-6571. Or your doctor or other prescriber can notify us over the phone and follow up by faxing or mailing the signed statement.

If your health requires it, ask us to give you a “fast decision”:

  • When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 72 hours after we receive your doctor’s statement. A fast decision means we will answer within 24 hours.
  • To get a fast decision, you must meet two requirements:
    • You can get a fast decision only if you are asking for a drug you have not yet received. (You cannot get a fast decision if you are asking us to pay you back for a drug you are already bought.)
    • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
  • If your doctor or other prescriber tells us that your health requires a “fast decision,” we will automatically agree to give you a fast decision.
  • If you ask for a fast decision on your own (without your doctor’s or other prescriber’s support), our plan will decide whether your health requires that we give you a fast decision.
    • If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter that says so (and we will use the standard deadlines instead).
    • This letter will tell you that if your doctor or other prescriber asks for the fast decision, we will automatically give a fast decision.
    • The letter will also tell how you can file a complaint about our decision to give you a standard decision instead of the fast decision you requested. It tells how to file a “fast” complaint, which means you would get our answer to your complaint within 24 hours.

Step 2: Our plan considers your request and we give you our answer.

Deadlines for a “fast” coverage decision:

  • If we are using the fast deadlines, we must give you our answer within 24 hours.
    • Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to.
    • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization.
  • If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor’s statement supporting your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Deadlines for a “standard” coverage decision about a drug you have not yet received:

  • If we are using the standard deadlines, we must give you our answer within 72 hours.
    • Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to.
    • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this section, we tell about this review organization and explain what happens at Appeal Level 2.
  • If our answer is yes to part or all of what you requested:
    • If we approve your request for coverage, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor’s statement supporting your request.
    • If we approve your request to pay you back for a drug you already bought, we are also required to send payment to you within 30 calendar days after we receive your request or doctor’s statement supporting your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Deadlines for a “standard” coverage decision about payment for a drug you have already bought:

  • We must give you our answer within 14 calendar days after we receive your request.
    • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. 
  • If our answer is yes to part or all of what you requested, we are also required to make payment to you within 30 calendar days after we receive your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Step 3: If we say no to your coverage request, you decide if you want to make an appeal.

  • If our plan says no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.

When you are admitted to a hospital, you have the right to get all of your covered hospital services that are necessary to diagnose and treat your illness or injury.  During your hospital stay, your doctor and the hospital staff will be working with you to prepare for the day when you will leave the hospital. They will also help arrange for care you may need after you leave.

  • The day you leave the hospital is called your “discharge date.” Our plan’s coverage of your hospital stay ends on this date.
  • When your discharge date has been decided, your doctor or the hospital staff will let you know.
  • If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay and your request will be considered. This section tells you how to ask.

During your inpatient hospital stay, you will get a written notice from Medicare that tells about your rights.

During your hospital stay, you will be given a written notice called An Important Message from Medicare about Your Rights. Everyone with Medicare gets a copy of this notice whenever they are admitted to a hospital. Someone at the hospital is supposed to give it to you within two days after you are admitted.  If you do not get the notice, ask any hospital employee for it.  If you need help, please call Customer Service.  You can also call 1-800-MEDICARE (1800-633-4227), 24 hours a day, 7 days a week.  TTY users should call 1-877-486-2048.

Read this notice carefully and ask questions if you don’t understand it. It tells you about your rights as a hospital patient, including:

  • Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them, and where you can get them.
  • Your right to be involved in any decisions about your hospital stay, and know who will pay for it.
  • Where to report any concerns you have about quality of your hospital care.
  • Your right to appeal your discharge decision if you think you are being discharged from the hospital too soon.

You must sign the written notice to show that you received it and understand your rights.

  • You or someone who is acting on your behalf must sign the notice.
  • Signing the notice shows only that you have received the information about your rights. The notice does not give your discharge date (your doctor or hospital staff will tell you your discharge date). Signing the notice does not mean you are agreeing on a discharge date.

Keep your copy of the signed notice so you will have the information about making an appeal (or reporting a concern about quality of care) handy if you need it.

  • If you sign the notice more than 2 days before the day you leave the hospital, you will get another copy before you are scheduled to be discharged.
  • To look at a copy of this notice in advance, you can call Member Services or 1-800- MEDICARE, 24 hours a day, 7 days a week (1-800-633-4227 or TTY: 1-877-486-2048). You can also see it online at http://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp.

 

If you want to ask for your hospital services to be covered by our plan for a longer time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are.

  • Follow the process. Each step in the first two levels of the appeals process is explained below.
  • Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do.
  • Ask for help if you need it. If you have questions or need help at any time, please call Customer Service at 1-800-329-2792 to initiate your coverage decision request. TTY users TYY 711; this number requires special telephone equipment and is only for people who have difficulties hearing or speaking.

    We are available:

    October 1 - February 14                8 a.m to 8 p.m., 7 days a week

    February 15 - Septemeber 30         8 a.m to 8 p.m., Monday - Friday

During non-business hours, your call will be answered by our automated phone system.  A Customer Service Representative will return your call on the next business day.

  • Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance.

Step 1: Contact the Quality Improvement Organization in your state and ask for a "fast review" of your hospital discharge. You must act quickly.

What is the Quality Improvement Organization?

  • This organization is a group of doctors and other health care professionals who are paid by the Federal government. These experts are not part of our plan. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. This includes reviewing hospital discharge dates for people with Medicare.

How can you contact this organization?

  • The written notice you received (An Important Message from Medicare) tells you how to reach this organization.

Act quickly:

  • To make your appeal, you must contact the Quality Improvement Organization before you leave the hospital and no later than your planned discharge date. (Your “planned discharge date” is the date that has been set for you to leave the hospital.)
    • If you meet this deadline, you are allowed to stay in the hospital after your discharge date without paying for it while you wait to get the decision on your appeal from the Quality Improvement Organization.
    • If you do not meet this deadline, and you decide to stay in the hospital after your planned discharge date, you may have to pay all of the costs for hospital care you receive after your planned discharge date.
  • If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to our plan instead.

Ask for a “fast review”:

  • You must ask the Quality Improvement Organization for a “fast review” of your discharge.  Asking for a “fast review” means you are asking for the organization to use the “fast” deadlines for an appeal instead of using the standard deadlines.

Step 2: The Quality Improvement Organization conducts an independent review of your case.

What happens during this review?

  • Health professionals at the Quality Improvement Organization (we will call them “the reviewers” for short) will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish.
  • The reviewers will also look at your medical information, talk with your doctor, and review information that the hospital and our plan has given to them.
  • By noon of the day after the reviewers informed our plan of your appeal, you will also get a written notice that gives your planned discharge date and explains the reasons why your doctor, the hospital, and our plan think it is right (medically appropriate) for you to be discharged on that date.

Step 3: Within one full day after it has all the needed information, the Quality Improvement Organization will give you its answer to your appeal.

What happens if the answer is yes?

  • If the review organization says yes to your appeal, our plan must keep providing your covered hospital services for as long as these services are medically necessary.
  • You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered hospital services.

What happens if the answer is no?

  • If the review organization says no to your appeal, they are saying that your planned discharge date is medically appropriate. If this happens, our plan’s coverage for your hospital services will end at noon on the day after the Quality Improvement Organization gives you its answer to your appeal.
  • If you decide to stay in the hospital, then you may have to pay the full cost of hospital care you receive after noon on the day after the Quality Improvement Organization gives you its answer to your appeal.

Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal.

If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make another appeal. Making another appeal means you are going on to “Level 2” of the appeals process

 

If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal. If the Quality Improvement Organization turns down your Level 2 Appeal, you may have to  pay the full cost for your stay after your planned discharge date.

Step 1: You contact the Quality Improvement Organization again and ask for another review.

You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you stayed in the hospital after the date that your coverage for the care ended.

Step 2: The Quality Improvement Organization does a second review of your situation.


Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal.

Step 3: Within 14 calendar days, the Quality Improvement Organization reviewers will decide on your appeal and tell you their decision.


If the review organization says yes:

  • Our plan must reimburse you for our share of the costs of hospital care you have received since noon on the day after the date your first appeal was turned down by the Quality Improvement Organization. Our plan must continue providing coverage for your inpatient hospital care for as long as it is medically necessary.
  • You must continue to pay your share of the costs and coverage limitations may apply.

If the review organization says no:

  • It means they agree with the decision they made to your Level 1 Appeal and will not change it. This is called “upholding the decision.” It is also called “turning down your appeal.”
  • The notice you get 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 the next level of appeal, which is handled by a judge.

Step 4: If the answer is no, you will need to decide whether you want to take your appeal further by going on to Level 3.

There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If the review organization turns down 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.

You can appeal to our plan instead.

You must act quickly to contact the Quality Improvement Organization to start your first appeal of your hospital discharge. (“Quickly” means before you leave the hospital and no later than your planned discharge date). If you miss the deadline for contacting this organization, there is another way to make your appeal.

 If you use this other way of making your appeal, the first two levels of appeal are different.

If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to our plan, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines.

Step 1: Contact our plan and ask for a "fast review."

  • Contact our plan by calling, writing or faxing us and ask for a “fast review.”
    • Call Customer Service at 1-800-329-2792 to initiate your coverage decision request.  TTY users TTY 711; this number requires special telephone equipment and is only for people who have difficulties hearing or speaking.

We are available:

October 1 - February 14
8 a.m. to 8 p.m., 7 days a week

February 15 - September 30
8 a.m. to 8 p.m., Monday - Friday

During non-business hours, your call will be answered by our automated phone system.  A Customer Service Representative will return your call on the next business day.

Or write to us at:

MSA Processing Center
P.O. Box 5204
Binghamton, NY 13902

Be sure to ask for a “fast review.” This means you are asking us to give you an answer using the “fast” deadlines rather than the “standard” deadlines.

Step 2: Our plan does a "fast" review of your planned discharge date, checking to see if it was medically appropriate.

  • During this review, our plan takes a look at all of the information about your hospital stay. We check to see if your planned discharge date was medically appropriate. We will check to see if the decision about when you should leave the hospital was fair and followed all the rules.
  • In this situation, we will use the “fast” deadlines rather than the standard deadlines for giving you the answer to this review.

Step 3: Our plan gives you our decision within 72 hours after you ask for a “fast review” (“fast appeal”).

  • If our plan says yes to your fast appeal, it means we have agreed with you that you still need to be in the hospital after the discharge date, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.)
  • If our plan says no to your fast appeal, we are saying that your planned discharge date was medically appropriate. Our coverage for your hospital services ends as of the day we said coverage would end.
  • If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you received after the planned discharge date. You will be responsible for the cost of care you received after the planned discharge date.

Step 4: If our plan says no to your fast appeal, your case will automatically be sent on to the next level of the appeals process.

To make sure we were being fair when we said no to your fast appeal, our plan is required to send your appeal to the “Independent Review Organization.” When we do this, it means that you are automatically going on to Level 2 of the appeals process.

 

If our plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our plan made when we said no to your “fast appeal.” This organization decides whether the decision we made should be changed.

Step 1: We will automatically forward your case to the Independent Review Organization.


We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal.  If you think we are not meeting this deadline or other deadlines, you an make a complaint. 

Step 2: The Independent Review Organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours.

  • The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.
  • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal of your hospital discharge.
  • If this organization says yes to your appeal, then our plan must reimburse you (pay you back) for our share of the costs of hospital care you have received since the date of your planned discharge. We must also continue the plan’s coverage of your hospital services 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 our plan that your planned hospital discharge date was medically appropriate.
    • The 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, which is handled by a judge.

Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further.

There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If reviewers say no to your Level 2 Appeal, you decide whether to accept their decision or go on to Level 3 and make a third appeal.

This section is about the following types of care only:

  • Home health care services you are getting.
  • Skilled nursing care you are getting as a patient in a skilled nursing facility.
  • Rehabilitation care you are getting as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are getting treatment for an illness or accident, or you are recovering from a major operation.

When you are getting any of these types of care, you have the right to keep getting your covered services for that type of care for as long as the care is needed to diagnose and treat your illness or injury.

When we decide it is time to stop covering any of the three types of care for you, we are required to tell you in advance. When your coverage for that care ends, our plan will stop paying its share of the cost for your care.

If you think we are ending the coverage of your care too soon, you can appeal our decision.

We will tell you in advance when your coverage will be ending.


You receive a notice in writing. At least two days before our plan is going to stop covering your care, the agency or facility that is providing your care will give you a notice.

  • The written notice tells you the date when our plan will stop covering the care for you.
  • The written notice also tells what you can do if you want to ask our plan to change this decision about when to end your care, and keep covering it for a longer period of time.

You must sign the written notice to show that you received it.

  • You or someone who is acting on your behalf must sign the notice.
  • Signing the notice shows only that you have received the information about when your coverage will stop. Signing it does not mean you agree with the plan that it’s time to stop getting the care.

If you want to ask us to cover your care for a longer period of time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are.

  • Follow the process. Each step in the first two levels of the appeals process is explained below.
  • Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do. There are also deadlines our plan must follow.
  • Ask for help if you need it. If you have questions or need help at any time, please call Member Services at 1-800-329-2792. TTY 711; this number requires special telephone equipment and is only for people who have difficulties hearing or speaking. 

We are available:

October 1 - February 14
8 a.m. to 8 p.m., 7 days a week

February 15 - September 30
8 a.m. to 8 p.m., Monday - Friday

During non-business hours, your call will be answered by our automated phone system.  A Customer Service Representative will return your call on the next business day.

  • Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance.

During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal and decides whether to change the decision made by our plan.

Step 1: Make your Level 1 Appeal: contact the Quality Improvement Organization in your state and ask for a review. You must act quickly.


What is the Quality Improvement Organization?

  • This organization is a group of doctors and other health care experts who are paid by the Federal government. These experts are not part of our plan. They check on the quality of care received by people with Medicare and review plan decisions about when it’s time to stop covering certain kinds of medical care.

How can you contact this organization?

  • The written notice you received tells you how to reach this organization.

What should you ask for?

  • Ask this organization to do an independent review of whether it is medically appropriate for our plan to end coverage for your medical services.

Your deadline for contacting this organization.

  • You must contact the Quality Improvement Organization to start your appeal no later than noon of the day after you receive the written notice telling you when we will stop covering your care.
  • If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to our plan instead.

Step 2: The Quality Improvement Organization conducts an independent review of your case.

What happens during this review?

  • Health professionals at the Quality Improvement Organization will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish.
  • The review organization will also look at your medical information, talk with your doctor, and review information that our plan has given to them.
  • By the end of the day rhe reviewers informed us of your appeal you will also get a written notice from the plan that gives our reasons for wanting to end the plan’s coverage for your services.

Step 3: Within one full day after they have all the information they need, the reviewers will tell you their decision.

What happens if the reviewers say yes to your appeal?

  • If the reviewers say yes to your appeal, then our plan must keep providing your covered services for as long as it is medically necessary.
  • You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered services.

What happens if the reviewers say no to your appeal?

  • If the reviewers say no to your appeal, then your coverage will end on the date we have told you. Our plan will stop paying its share of the costs of this care.
  • If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will have to pay the full cost of this care yourself.

Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal.

  • This first appeal you make is “Level 1” of the appeals process. If reviewers say no to your Level 1 Appeal – and you choose to continue getting care after your coverage for the care has ended – then you can make another appeal.
  • Making another appeal means you are going on to “Level 2” of the appeals process.

 

If the Quality Improvement Organization has turned down your appeal and you choose to continue getting care after your coverage for the care has ended, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal. If we turn down your Level 2 Appeal, you may have to pay the full cost for your home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end.

Step 1: You contact the Quality Improvement Organization again and ask for another review.


You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended.

Step 2: The Quality Improvement Organization does a second review of your situation.


Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal.

Step 3: Within 14 days, the Quality Improvement Organization reviewers will decide on your appeal and tell you their decision.


What happens if the review organization says yes to your appeal?

  • Our plan must reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. Our plan must continue providing coveragefor the care for as long as it is medically necessary.
  • You must continue to pay your share of the costs and there may be coverage limitations that apply.

What happens if the review organization says no?

  • It means they agree with the decision they made to your Level 1 Appeal and will not change it.
  • The notice you get 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 the next level of appeal, which is handled by a judge.

Step 4: If the answer is no, you will need to decide whether you want to take your appeal further.

There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If reviewers turn down 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.

You can appeal to us instead

You must act quickly to contact the Quality Improvement Organization to start your first appeal (within a day or two, at the most). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different.

Step-by-Step: How to make a Level 1 Alternate Appeal

If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines.

Here are the steps for a Level 1 Alternate Appeal:

Step 1: Contact us and ask for a “fast review.”

  • For details on how to contact us, go to Chapter 2, Section 1 and look for the section called,  How to contact us when you are making an appeal about your medical care.

Be sure to ask for a “fast review.” This means you are asking us to give you an answer using the “fast” deadlines rather than the “standard” deadlines.

Step 2: We do a “fast” review of the decision we made about when to end coverage for your services.

  • During this review, we take another look at all of the information about your case. We check to see if we were following all the rules when we set the date for ending the plan’s coverage for services you were receiving.
  • We will use the “fast” deadlines rather than the standard deadlines for giving you the answer to this review. (Usually, if you make an appeal to our plan and ask for a “fast review,” we are allowed to decide whether to agree to your request and give you a “fast review.” But in this situation, the rules require us to give you a fast response if you ask for it.)

Step 3: We give you our decision within 72 hours after you ask for a “fast review” (“fast appeal”).

If we say yes to your fast appeal, it means we have agreed with you that you need services longer, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.)

If we say no to your fast appeal, then your coverage will end on the date we told you and we will not pay any share of the costs after this date.

  • If you continued to get home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end, then you will have to pay the full cost of this care yourself.

Step 4: If we say no to your fast appeal, your case will automatically go on to the next level of the appeals process.

To make sure we were following all the rules when we said no to your fast appeal, we are required to send your appeal to the “Independent Review Organization.” When we do this, it means that you are automatically going on to Level 2 of the appeals process.

Step-by-Step: How to make a Level 2 Alternate Appeal

If we say no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your “fast appeal.” This organization decides whether the decision we made should be changed.

Step 1: We will automatically forward your case to the Independent Review Organization.

  • We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. The complaint process is different from the appeal process. Section 10 of this chapter tells how to make a complaint.)

Step 2: The Independent Review Organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours.

  • The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.
  • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal.

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 first appeal and will not change it.

  • The 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.

  • There are three additional levels of appeal after Level 2, for a total of five 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.

 

 

 

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.

  • If the Administrative Law Judge says yes, 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.
    • 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, 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 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.
  • 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. It depends on your situation. 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.
  • A judge at the Federal District Court will review your appeal
    • This is the last step of the administrative appeals process.

If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. You, your appointed representative, or your prescriber may use this form to request a redetermination (appeal) from your plan sponsor.

Step 1: You ask our plan to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a “fast decision.” You cannot ask for a fast decision if you are asking us to pay you back for a drug you already bought.

What to do

  • Request the type of coverage decision you want. Start by writing, or faxing our plan to make your request. You, your representative, or your doctor (or other prescriber) can do this.
  • You or your doctor or someone else who is acting on your behalf can ask for a coverage decision. Chapter 9, Section 4 of your MA-PD Evidence of Coverage tells you how you can give written permission to someone else to act as your representative*. You can also have a lawyer act on your behalf.
  • If you want to ask us to pay you back for a drug, start by reading Chapter 7 of your MA-PD Evidence of Coverage: Asking us to pay our share of a bill you have received for covered medical services or drugs. Chapter 7 describes the situations in which you may need to ask for reimbursement. It also tells how to send us the paperwork that asks us to  pay you back for our share of the cost of a drug you have paid for.
  • If you are requesting an exception, provide the “doctor’s statement.” Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. (We call this the “doctor’s statement.”) Your doctor or other prescriber can fax (1-888-333-4316) or mail the statement to our plan at PO Box 62, Buffalo NY 14240-0062. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing the signed statement.

If your health requires it, ask us to give you a “fast decision”

  • When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 72 hours after we receive your doctor’s statement. A fast decision means we will answer within 24 hours.
  • To get a fast decision, you must meet two requirements:
    • You can get a fast decision only if you are asking for a drug you have not yet received. (You cannot get a fast decision if you are asking us to pay you back for a drug you are already bought.)
    • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
  • If your doctor or other prescriber tells us that your health requires a “fast decision,” we will automatically agree to give you a fast decision.
  • If you ask for a fast decision on your own (without your doctor’s or other prescriber’s support), our plan will decide whether your health requires that we give you a fast decision.
    • If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter that says so (and we will use the standard deadlines instead).
    • This letter will tell you that if your doctor or other prescriber asks for the fast decision, we will automatically give a fast decision.
    • The letter will also tell how you can file a complaint about our decision to give you a standard decision instead of the fast decision you requested. It tells how to file a “fast” complaint, which means you would get our answer to your complaint within 24 hours.

Step 2: Our plan considers your request and we give you our answer.

Deadlines for a “fast” coverage decision

  • If we are using the fast deadlines, we must give you our answer within 24 hours.
    • Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to.
    • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization.
  • If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor’s statement supporting your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Deadlines for a “standard” coverage decision about a drug you have not yet received

  • If we are using the standard deadlines, we must give you our answer within 72 hours.
    • Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to.
    • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this section, we tell about this review organization and explain what happens at Appeal Level 2.
  • If our answer is yes to part or all of what you requested –
    • If we approve your request for coverage, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor’s statement supporting your request.
    • If we approve your request to pay you back for a drug you already bought, we are also required to send payment to you within 30 calendar days after we receive your request or doctor’s statement supporting your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Deadlines for a “standard” coverage decision about payment for a drug you have already bought

  • We must give you our answer within 14 calendar days after we receive your request.
    • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. 
  • If our answer is yes to part or all of what you requested we are also required to make payment to you within 30 calendar days after we receive your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Step 3: If we say no to your coverage request, you decide if you want to make an appeal.

If our plan says no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.

 

This section explains how to use the process for making complaints. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process.

If you have any of these kinds of problems, you can “make a complaint”

 

Quality of your medical care

  • Are you unhappy with the quality of the care you have received (including care in the hospital)?

Respecting your privacy

  • Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?

Disrespect, poor customer service, or other negative behaviors

  • Has someone been rude or disrespectful to you?
  • Are you unhappy with how our Member Services has treated you?
  • Do you feel you are being encouraged to leave the plan?

Waiting times

  • Are you having trouble getting an appointment, or waiting too long to get it?
  • Have you been kept waiting too long by doctors, pharmacists, or other health professionals? Or by our Member Services or other staff at the plan?
  •  Examples include waiting too long on the phone, in the waiting room, when getting a prescription, or in the exam room.

Cleanliness

  •  Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor’s office?

Information you get from us

  • Do you believe we have not given you a notice that we are required to give?
  • Do you think written information we have given you is hard to understand?

These types of complaints are all related to the timeliness of our actions related to coverage decisions and appeals

The process of asking for a coverage decision and making appeals is explained in your Evidence of Coverage.

However, if you have already asked us for a coverage decision or made an appeal, and you think that we are not responding quickly enough, you can also make a complaint about our slowness. Here are examples:

  • If you have asked us to give you a “fast coverage decision” or a “fast appeal,” and we have said we will not, you can make a complaint.
  • If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint.
  • When a coverage decision we made is reviewed and we are told that we must cover or reimburse you for certain medical services or drugs, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint.

When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a complaint.

Step-by-step: Making a complaint

Step 1: Contact us promptly – either by phone or in writing.

  • Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. Member Services can be reached at 1-800-329-2792 (TTY only, call TTY 711).  Hours are 8 a.m. to 8 p.m. seven days a week, October 1 to February 14 and 8 a.m. to 8 p.m. Monday through Friday, February 15 to September 30.
  • If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.
  • Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.
  • If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast 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.

Step 2: We look into your complaint and give you our answer.

  • If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
  • Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.
  • If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

You can also make complaints about quality of care to the Quality Improvement Organization

You can make your complaint about the quality of care you received to us by using the step-by-step process outlined above.

When your complaint is about quality of care, you also have two extra options:

  • You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to us).
  • The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients.
  • To find the name, address, and phone number of the Quality Improvement Organization for your state, look in Chapter 2, Section 4, of this booklet. If you make a complaint to this organization, we will work with them to resolve your complaint.
  • Or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to us and also to the Quality Improvement Organization.

You can also tell Medicare about your complaint

You can submit a complaint directly to Medicare. To submit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.

If you have any other feedback or concerns, or if you feel the plan is not addressing your issue, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.

 

 

 

 



 

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This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. 

Out-of-network/non-contracted providers are under no obligation to treat BlueShield of Northeastern New York members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

BlueShield of Northeastern New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal.

A division of HealthNow New York Inc., and independent licensee of the BlueCross BlueShield Association. A salesperson will be present with information and applications. For accommodations of persons with special needs at sales meetings, please call 1-800-329-2792 (TTY 711). BlueShield of Northeastern New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-329-2792 (TTY: 711).

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Content Last Updated October 1, 2017