10.0 Medicare Advantage Programs

Transcription

1 10.0 Medicare Advantage Programs This section is intended for providers who participate in Medicare Advantage programs, including Medicare Blue PPO. In addition to every other provision of the Participating Provider Manual, the following provisions apply with regard to all Medicare Advantage health benefit programs. For the purposes of this section: Appeal means any of the procedures that apply to the review of adverse determinations on the health care services a member believes he/she is entitled to receive, including delay in arranging for or providing health care services (such that a delay would adversely affect the member s health), or on any amounts the member must pay for services. These procedures include reconsideration by the Health Plan and, if necessary, an independent review entity; hearings before Administrative Law Judges, review by the Departmental Appeals Board and judicial review. Complaint means any expression of dissatisfaction made by a member, orally or in writing, to the Health Plan, a provider or a Quality Improvement Organization. This can include concerns about waiting times, the demeanor of health care personnel, the adequacy of facilities, the respect paid to the member, the claims regarding the right of a member to receive services or receive payment for services previously rendered. It also may include a member s disagreement with the Health Plan s refusal to provide services to which the member believes he/she is entitled. A complaint may be a grievance, an appeal or both. Contract means the contract between the Medicare Advantage Health Plan and the Centers for Medicare & Medicaid Services (CMS) whereby the Health Plan agrees to provide covered services to members. Covered Services means all health care services covered by a Medicare Advantage health benefit program. Grievance means any complaint or dispute (other than one involving an organization determination) expressing dissatisfaction with the manner in which the Health Plan or its delegates provides services, regardless of whether any remedial action can be taken. A member may make the complaint or dispute, either orally or in writing, to the Health Plan or to a participating provider. A grievance may also include a complaint that the Health Plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frames. Member means a Medicare Advantage beneficiary who is duly enrolled in a Medicare Advantage health benefit program, such as Medicare Blue PPO. Organization Determination means any decision made by or on behalf of the Health Plan regarding payment or services to which a member believes he/she is entitled. January

2 10.0 Medicare Advantage Programs Excellus BlueCross BlueShield Participation Agreement means the agreement between a Medicare Advantage health plan and any provider for the provision of covered services to members, either directly or through an intermediary organization. Provider means any health care services provider with whom a Medicare Advantage health plan contracts, either directly or through an intermediary organization, for the provision of covered services to members. Quality Improvement Organization (QIO) means an organization composed of practicing doctors and other health care experts under contract to the federal government to monitor and improve care given to Medicare enrollees. Quality of Care Issues may be filed through the Health Plan s grievance process and or through a Quality Improvement Organization (QIO). A QIO must determine whether the quality of services (both inpatient and outpatient services) provided by the Health Plan meets professionally recognized standards of care. Urgently Needed Services are covered services that are not emergency services (see Glossary in Section 12 for a definition of emergency services) and that are provided to a member when the member is temporarily absent from the Health Plan s service area when the services are medically necessary and immediately required and (i) are a result of an unforeseen illness, injury or condition or (ii) it is not reasonable given the circumstances to obtain services through Health Plan contracted providers Program Summary Medicare Blue PPO is a Medicare Advantage program. The Health Plan has contracted with CMS to provide managed Medicare services to Medicare beneficiaries. The contract with CMS stipulates that the Health Plan agrees to comply with Medicare s published regulations governing the provision of managed Medicare services to Medicare recipients. The Health Plan uses the Medicare regulations and guidelines to determine coverage and reimbursement Eligibility and Enrollment Enrolling in, or disenrolling from a Medicare Advantage program such Medicare Blue PPO is a beneficiary election and is subject to federal government regulations. CMS has established periods in which a beneficiary may make an election. For some such periods, there is a limit on the number of elections that may be made. Medicare beneficiaries may enroll in a Medicare Advantage program if they are covered by both Parts A and B of Medicare, continue to pay the Part B premium, and meet other eligibility requirements. According to federal regulation, Medicare Advantage members may disenroll from Medicare Advantage programs by: 10 2 January 2005

3 Participating Provider Manual 10.0 Medicare Advantage Programs Completing a disenrollment form and sending it to the Health Plan s Customer Service department. (For Health Plan address and phone numbers, see the Contact List in Section 2.) Preparing and signing a letter requesting that they be disenrolled, and sending it to the Health Plan. In most cases, disenrollment requests received on or before the last business day of the month will be effective on the first day of the following month. Election period rules and limits may apply. Members may also disenroll at any Social Security or Railroad Retirement Board office. Members may be disenrolled if they: Lose Part B of their Medicare benefits, Move outside the service area permanently, Reside outside the service area for six consecutive months or more, Fail to pay monthly premiums, or Fail to fulfill Member Responsibilities, including the responsibility to be courteous and respectful to providers, staff, and fellow patients Discrimination Prohibited Source: Medicare Managed Care Manual, Chapter 4, Section 100. The Health Plan may not deny, limit, or condition the coverage or furnishing of benefits to individuals eligible to enroll in one of its Medicare Advantage health benefit programs on the basis of any factor related to the member s health status, including but not limited to: Medical condition, including mental as well as physical illness; Claims experience; Receipt of health care; Medical history; Genetic information; Evidence of insurability, including conditions arising out of acts of domestic violence; or Disability. The Health Plan may not disenroll a member who develops end stage renal disease while enrolled in a Medicare Advantage program. The Health Plan observes the provisions of the Civil Rights Act, the Age Discrimination Act, the Rehabilitation Act of 1973, and the Americans with Disabilities Act. The Health Plan has procedures in January

4 10.0 Medicare Advantage Programs Excellus BlueCross BlueShield place so that a member is not discriminated against in the delivery of health care services consistent with the benefits covered in the member s policy based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment General Coverage Information Source: Medicare Managed Care Manual, Chapter 4, sections 10.2,10.7,130 This section details some of the general benefits that, according to CMS, Medicare Advantage benefit packages must include. Members of Medicare Blue PPO receive many other benefits in addition to those listed here. For details, see Section 11.0, Product Overviews. Note: For benefit information specific to a Medicare Blue PPO member, call Provider Service. Telephone number is included on the Contact List in Section 2 of this manual. According to CMS, all Medicare Advantage benefit packages must offer coverage that includes: No waiting periods or exclusions due to pre-existing conditions; Ambulance services dispatched through 911 or its local equivalent where other means of transportation would endanger the member s health (42 CFR ); Emergency and urgently needed services supplied without prior authorization, whether the services are obtained from participating or non-participating providers; Maintenance and post-stabilization care services: that is, covered services related to an emergency medical condition and which are provided after the member is stabilized either to maintain the member s stabilized condition or, under certain circumstances to improve or resolve the member s condition; Medically necessary dialysis from any qualified provider that member selects when the member is temporarily absent from the Health Plan s service area and he/she cannot reasonably access the Health Plan s contracted dialysis providers; Screening mammography and influenza vaccinations which require no referral and no copayment; Medically necessary inpatient rehabilitation services for 60 days, plus 30 coinsurance days January 2005

5 Participating Provider Manual 10.0 Medicare Advantage Programs Member Protections Providers shall cooperate with the Health Plan to ensure that an initial assessment of each member s health care needs is completed within 90 days after the effective date of enrollment. Providers shall provide covered services to members in a manner consistent with professionally recognized standards of health care. Providers may not hold any member liable for payment of any fee that is the legal obligation of the Health Plan. Providers must continue to provide covered services to members for the duration of the contract period for which CMS has made payments to the Health Plan. In the event that (i) the Health Plan s contract with CMS terminates, or (ii) the Health Plan becomes insolvent, participating providers must continue to provide covered services through the date of discharge to all members who are hospitalized Quality Assurance and Improvement The Health Plan has agreements with a CMS-approved independent Quality Improvement Organization (QIO) under which the QIO conducts reviews required by CMS. Providers shall cooperate with the activities of a QIO approved by CMS in connection with the provision of covered services to members, including providing the QIO with pertinent patient care data such as information on health outcomes and information on Medicare enrollee satisfaction. Providers shall participate in and cooperate with any Quality Assurance, Quality Improvement, and/or Resource Management program established or adopted by the Health Plan. The Health Plan shall consult with, and solicit input from, providers regarding the Health Plan s medical policy, quality assurance program, and medical management procedures. Providers agree to cooperate with the Health Plan to ensure that the following standards are met: Practice guidelines and utilization management guidelines are based on reasonable medical evidence or a consensus of health care professionals in the particular field, consider the needs of the enrolled population, and are developed in consultation with contracting health care professionals, and are reviewed and updated periodically. Guidelines are communicated to providers and, as appropriate, to members. Decisions with respect to utilization management, member education, coverage of services, and other areas in which the guidelines apply are consistent with the guidelines. January

6 10.0 Medicare Advantage Programs Excellus BlueCross BlueShield 10.2 Provider Obligations The obligations of each participating provider that are specifically applicable to Medicare enrollees are detailed in the provider s agreement with the Health Plan, including obligations the Health Plan delegates to the provider and obligations the Health Plan permits the provider to delegate or subcontract. The agreement also stipulates requirements and conditions for: Reporting and Disclosure Accountability Claims Turnaround Time Termination of Participation in a Medicare Contract 10.3 Medicare Advantage Coding Review and Provider Inquiry Report CMS has implemented a risk-adjusted payment methodology for Medicare Advantage programs. The methodology is based on diagnostic information as well as demographic information. The Health Plan will be conducting ICD-9 Coding Validation Reviews of all claims submitted by physicians who participate in Medicare Advantage benefit packages: i.e., Medicare Blue PPO. The code review will help the Health Plan comply with CMS regulations and assist participating physicians in achieving maximum appropriate reimbursement. (Refer to the information on accurate and complete ICD-9 coding in Section 8, Billing and Reimbursement, of this manual.) The Health Plan will document results of the ongoing coding review in an individualized Provider Inquiry Report (PIR) that will be sent to the office of each physician who participates in the Medicare Advantage provider network. For each claim in question, the report will list patient identification information, the diagnostic data submitted on the claim, a medical record review question and information about related diagnostic codes, if applicable. A physician or his/her staff should review the Provider Inquiry Report and, for each claim: Compare the data on the report with the information available from the patient s medical record. Mark the appropriate boxes on the report for each additional diagnosis code documented in the medical record, and enter the encounter date for each. Write in any other applicable diagnosis codes where indicated January 2005

7 Participating Provider Manual 10.0 Medicare Advantage Programs Once completed, the physician should sign and date the report and mail or fax it to the Health Plan s Data Quality Department. (See Data Quality address under Medicare Advantage Coding Review on the Contact List in Section 2 of this manual.) For more information about the ICD-9 Coding Validation Review or the Provider Inquiry Report, call the Medicare Advantage Coding Review number on the Contact List in Section Member Grievances, Organization Determinations and Appeals Source: Medicare Managed Care Manual, Chapter 13, Relative to grievances, organization determinations and appeals, the rights of a member of a Medicare Advantage program include, but are not limited to, the following: The right to have grievances heard and resolved in accordance with the guidelines described in Section The right to request from the Health Plan quality of care grievance data. The right to a timely organization determination (Section 10.6). The right to request an expedited organization determination (Section ). The right to receive from a provider information regarding the member s right to obtain a detailed written notice from the Health Plan regarding the member s services (Section ). The right to receive from the Health Plan a detailed written notice of the Health Plan s decision to deny, terminate or reduce service in whole or in part, which includes the member s right to appeal (Section ). The right to request an expedited appeal and the right to receive notice when an appeal is forwarded to the independent review entity (Section ). The right to automatic reconsideration by an independent review entity (IRE) when the Health Plan upholds its original adverse determination in whole or in part (see Section ). The right to an Administrative Law Judge (ALJ) hearing if the IRE upholds the original adverse determination in whole or in part, and the remaining amount in controversy is $100 or more (Section ). The right to request Departmental Appeals Board (DAB) review if the ALJ hearing decision is unfavorable to the member in whole or in part (Section ). January

8 10.0 Medicare Advantage Programs Excellus BlueCross BlueShield The right to judicial review of the hearing decision if the ALJ hearing and/or the DAB review is unfavorable to the member in whole or in part and the amount remaining in controversy is $1,000 or more (Section ). The right to make a quality of care complaint under the Quality Improvement Organization (QIO) process (Section ). The right to request a QIO review of a determination of noncoverage of inpatient hospital care (Section ). The right to request a QIO review of a determination of noncoverage in skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities (see Section ). The right to request and be given timely access to the member s case file and a copy of that file, subject to federal and state laws regarding confidentiality of patient information. (The Health Plan has the right to charge the member a reasonable amount for duplicating the case file material.) The right to challenge local and national coverage determinations. For more information about these and other member rights, contact Provider Service. (See Section 2 for Contact List.) 10.5 Grievances Among the reasons a member of a Medicare Advantage program may file a grievance with the Health Plan are the following: Problems with the quality of care, including quality of care during a hospital stay; Disagreement with the Health Plan s denial of the member s request for an expedited ( fast ) appeal; Disagreement with the Health Plan s decision to extend the time frame for making an initial decision or appeal, in which case the member may request an expedited ( fast ) grievance; Believing that the member is being encouraged to disenroll from a Medicare Advantage program; Problems with Customer Service; Problems with waiting on the phone, in a provider s waiting room, or in a provider s examination room; Problems with getting appointments when needed, or in a timely fashion; Disrespectful or rude behavior by providers, receptionists or other staff; Cleanliness or condition of providers offices, clinics or hospitals; 10 8 January 2005

9 Participating Provider Manual 10.0 Medicare Advantage Programs Complaints regarding physician behavior and demeanor, adequacy of facilities and other similar member concerns; and Involuntary disenrollment situations (although disenrollment for cause requires prior CMS approval). Procedure Note: The grievance procedures presented in this section do not apply whenever the Medicare Reconsideration/Appeals Procedures are applicable. 1. Members may register a grievance by phone, mail or in person. 2. The Health Plan will respond to most grievances in writing within forty-five (45) days. However, if the member is filing the grievance because the Health Plan has determined not to give the member an expedited initial decision or an expedited appeal on a request for service, or if the Health Plan extends the time frame of an initial decision or appeal, the Health Plan will respond within 24 hours. All decision notifications will include information about the basis of the Health Plan s decision and describe further Second Level Grievance rights, if applicable. Grievances involving clinical decisions will be made by qualified clinical personnel. Members have the right to have a representative file and/or pursue a Grievance or Second Level Grievance on their behalf. 3. If the Health Plan makes an adverse determination and the member is not satisfied with that decision, the member has the right to file a Second Level Grievance. To do so, the member must submit a written request to the Health Plan within sixty (60) days after receiving a denial. A Health Plan Medical Director or his/her designee will review the member s Second Level Grievance. 4. The Health Plan will respond to the Second Level Grievance in writing within thirty (30) working days of receipt of the member s request Organization Determinations Source: Medicare Managed Care Manual, Chapter 13, Section 30. Note: This section applies ONLY to Medicare Advantage programs. For information about the Health Plan s utilization review process as applicable to other health benefit programs, see Section 4 of this manual. An organization determination is any determination (that is, an approval or denial) that the Health Plan makes for a member of a Medicare Advantage health benefit program regarding: January

10 10.0 Medicare Advantage Programs Excellus BlueCross BlueShield Payment for any other health care services furnished by a provider that the Medicare Advantage enrollee believes are covered under Medicare or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the Medicare Advantage organization. Refusal to preauthorize, provide, or pay for services, in whole or in part, including the type or level of services which a Medicare Advantage enrollee believes should be furnished or arranged for by the Health Plan. Discontinuation of a service that a Medicare Advantage member believes should be continued because he/she believes the service to be medically necessary. Failure of the Medicare Advantage organization to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of adverse determination, such that a delay would adversely affect the health of the enrollee. This section describes the procedures the Health Plan has established for making timely organization determinations regarding the benefits a member is entitled to receive under its Medicare Advantage programs. Once an organization determination has occurred, the appeals process may be triggered if a member believes that the Health Plan s decision is unfavorable. In the presence of any adverse organization determination that is, when the Health Plan determines that it will not provide or pay for a requested service, in whole or in part the Health Plan will send the member a written denial notice that includes appeal rights. If a member of a Medicare Advantage program disputes an organization determination, the Health Plan will follow the procedures outlined in Section If a member complains about any other aspect of the Medicare Advantage organization, (e.g., the manner in which care was provided), the grievance process described in Section 10.5 will apply. Generally, the Health Plan will consider complaints about quality of care as a grievance, but such complaints may also be received and acted upon by a Quality Improvement Organization (QIO). (See Section 10.8.) Standard Organization Determinations Source: Medicare Managed Care Manual, Chapter 13, Section 40. When a member of a Medicare Advantage program requests a service, the Health Plan must notify the member of its determination as expeditiously as the member s health condition requires, but no later than 14 calendar days after the date the Health Plan receives the request for a standard organization determination. The Health Plan may extend the time frame up to an additional 14 days if the member requests the extension, or if the Health Plan justifies and documents the need for additional information. The Health Plan will notify the member in writing of its decision to extend the January 2005

11 Participating Provider Manual 10.0 Medicare Advantage Programs time frame, and inform the member of his/her right to file a grievance if he/she disagrees with the extension. If the Health Plan fails to provide the member with a timely notice of an adverse determination, this failure itself constitutes an adverse organizational determination and may be appealed Expedited (or Fast ) Organization Determinations Source: Medicare Managed Care Manual, Chapter 13, Section 50. A member of a Medicare Advantage program or any physician may request that the Health Plan expedite an organization determination when the member or his/her physician believes that waiting for a decision under the standard time frame could place the member s life, health, or ability to regain maximum function in serious jeopardy. Note: Expedited determinations may not be requested for cases in which the only issue involves a claim for payment for services that the member has already received. However, if the case includes both a payment denial and a pre-service denial, the member has a right to request an expedited appeal for the pre-service denial. The Health Plan will evaluate a request for an expedited determination and decide within 24 hours whether the request will receive it. If the member s physician initiated the request for a fast determination, or if the member initiated the request for a fast determination with the support of his/her physician, the Health Plan automatically will expedite the determination. If the Health Plan denies a request for a fast determination, the Health Plan will provide verbal notice of the denial within 24 hours, with a written notice to follow within two working days. The Health Plan may take an additional 14 calendar days if the member requests the extension, or if it is to the member s benefit. The notice will state that the request will be processed using the timeframe for standard determinations (Section ), and that the member has the right to resubmit the request for an expedited determination or file with Customer Service an expedited grievance regarding this decision. The notice also will provide instructions on how to file a grievance (Section 10.5) Notification of Adverse Determinations Source: Medicare Managed Care Manual, Chapter 13, Section 40. Notification by Provider In situations where a member disagrees with a provider s decision about a service or course of treatment, the provider must notify the member of his/her right to receive from the Health Plan a detailed written notice regarding the member s services. The provider s notification must include information about how to contact the Health Plan. January

12 10.0 Medicare Advantage Programs Excellus BlueCross BlueShield Notification by the Health Plan If a member asks the Health Plan to provide a detailed notice of a provider s decision to deny a service (as described above) in whole or in part, or if the Health Plan decides to deny in whole or in part services or payment, the Health Plan must supply the member with a written notice of this determination. This written notice will include: The specific reason for the denial that takes into account the member s presenting medical condition, disabilities, and special language requirements, if any; Information regarding the member s right to a standard or expedited determination and the right to appoint a representative to file an appeal on the member s behalf; For service denials, a description of both the standard and expedited reconsideration process and time frames, including conditions for obtaining an expedited reconsideration, and the other elements of the appeal process; For payment denials, a description of the standard reconsideration process and time frames, and the rest of the appeals process; and The member s right to submit additional evidence in writing or in person Appeals Process Source: Medicare Managed Care Manual, Chapter 13, Section 60. There are five levels of appeal available to members of Medicare Advantage health benefit programs following the receipt of notification of an adverse organization determination. These levels are to be followed sequentially only if the original denial continues to be upheld by the reviewing entity. Reconsideration of an adverse organization determination made by the Health Plan (Section ); Reconsideration of an adverse organization determination made by an independent review entity (Section ); Hearing by an Administrative Law Judge, if at least $100 is at issue (Section ); Review by a Departmental Appeals Board (Section ); and Federal Court Review if at least $1000 is at issue (Section ). An initial, revised or reconsideration determination made by the Health Plan, CMS, an administrative law judge, or the Departmental Appeals Council can be reopened (a) within twelve months, (b) within four years for just cause, or (c) or at any time for clerical correction or in cases of fraud January 2005

13 Participating Provider Manual 10.0 Medicare Advantage Programs Right to Appeal A member has the right to an appeal (also called a reconsideration ) if he/she does not agree with the Health Plan s decision about medical bills or health care (i.e., after receiving an adverse organization determination). A member may appeal if he/she believes: The Health Plan has not paid a bill. The Health Plan has not paid a bill in full. The Health Plan will not approve or give care it should cover, or a provider will not provide care or referrals the member thinks he or she needs. The Health Plan is stopping care that the member still needs. Note: If a member is discharged from a hospital and the member feels it is too soon, the member must request an immediate QIO review (see Section 10.8). The member may remain in the hospital without becoming financially liable until the QIO makes its decision Who May Request Reconsideration A member may act on his/her own behalf. A member may appoint an authorized representative to act on his/her behalf, e.g., a doctor, a friend, or a lawyer. To appoint an authorized representative, the member must: Prepare a statement that lists the member s name, Medicare number, and appoints an individual as his/her authorized representative. For example: I, (Member Name), (Medicare Number) appoint (name of representative) to act as my authorized representative in requesting an appeal from the Health Plan and/or the Centers for Medicare & Medicaid Services regarding the Health Plan s (denial or services) or (denial of payment for services.) Sign and date the statement. Have the authorized representative sign and date the statement. Include this signed statement with his/her request for a Determination of Appeal. A provider who does not participate with the specific Medicare Advantage program may file a standard appeal of a denied claim if he/she completes a waiver of liability statement that says he/she will not bill the member regardless of the outcome of the appeal. A court-appointed guardian or an agent under a health care proxy may act as the member s representative to the extent provided under New York State law. January

14 10.0 Medicare Advantage Programs Excellus BlueCross BlueShield Support for Member Appeals The Health Plan must gather all the information it needs to make a decision about the member s appeal. If the Health Plan requires the member's assistance in gathering this information, the Health Plan will contact the member directly. A member has the right to obtain and include additional information as part of his/her appeal. For example, a member may already have documents related to the issue, or he/she may want to obtain his/her provider s records or the provider s written opinion to help support the request. The provider may ask the member to submit a written request in order to obtain such information How to Request a Standard Reconsideration A member of a Medicare Advantage Program or his/her authorized representative must file a written request for appeal with the Health Plan within 60 days of receiving a notification of adverse organization determination from the Health Plan. (If shown good cause to do so, the Health Plan may extend the time frame for filing.) The request may be mailed, faxed or hand-delivered to the Health Plan (for Health Plan address and fax numbers, see the Contact List in Section 2). Note: A member also may file an appeal with an office of the Social Security Administration or, if the member is a railroad annuitant, with the Railroad Retirement Board. These offices will transfer the member s request to the Health Plan for processing. The time frame for review does not begin until the Health Plan receives the request for reconsideration Reconsideration by the Health Plan Standard 30-day Appeals The Health Plan normally has 30 calendar days after receipt to process a member s request for reconsideration. A faster, 72-hour appeal is also available if waiting 30 days for a standard appeal could seriously harm the member s health or ability to function (see Expedited 72-hour Appeals, below). The Health Plan has 30 days to process a member s appeal regarding claims payment or reimbursement. The expedited process is not available for these types of appeals. The Health Plan may extend the timeframe by up to 14 calendar days if the member requests the extension, or if it is to the member s benefit. The Health Plan must notify the member of its intent to extend the time frame before the end of the 30 days January 2005

15 Participating Provider Manual 10.0 Medicare Advantage Programs Expedited 72-hour Appeals The member, any physician, or the member s authorized representative can request a fast appeal rather than a standard appeal for a decision about medical care. If any physician asks for a fast decision on a member s behalf, or supports a member in his/her request for one, and the physician indicates that waiting for a standard decision could seriously harm the member s health or ability to function, the Health Plan will automatically grant the member a fast decision. If the member requests a fast appeal without support from a physician, the Health Plan will decide if the member s health requires it. If the Health Plan decides that the member s medical condition does not meet the requirements for a fast appeal, the Health Plan will send the member a letter that explains that, if the member gets a physician s support for a fast appeal, the Health Plan will automatically make a fast decision. The letter will also explain how the member may file a Grievance if the member disagrees with the Health Plan s decision to deny the member s request for a fast appeal. Once the Health Plan denies a member s request for a fast initial decision, the Health Plan will make its decision within the standard time frame (as explained in Standard 30-day Appeals, above). Note: If, after requesting an appeal, a member wishes to withdraw the appeal, he/she must do so by sending a written notice to Customer Service (for Health Plan address and phone numbers, see the Contact List in Section 2). Following the Reconsideration If, following standard or expedited reconsideration, the Health Plan does not rule fully in the member s favor, the member s appeal automatically goes to the next level where the case is reviewed by the Center for Health Dispute Resolution (CHDR), an independent organization contracted by CMS (see Section ). The member s appeal also must be forwarded to CHDR if the Health Plan fails to provide the member with a reconsidered determination within the time frames specified above Reconsideration by the Center for Health Dispute Resolution (CHDR) The second level in the appeals process is reconsideration by the Center for Health Dispute Resolution a contractor for the Centers for Medicare & Medicaid Services. In making its decision, CHDR will follow these time frames: For standard requests for service, the Health Plan must forward the member s file to CHDR no later than 30 calendar days from the date the Health Plan received the member s request (or no later than expiration of the extension). For expedited reconsiderations, the Health Plan must forward the member s file to CHDR no later than 24 hours after the Health Plan made its decision. CHDR is responsible for notifying all parties of its decision. Notification will include the decision, the reasons for the decision and, if the amount in controversy is $100 or more or if the Center s decision is January

16 10.0 Medicare Advantage Programs Excellus BlueCross BlueShield adverse, information about the member s rights to a hearing before an administrative law judge of the Social Security Administration Hearing before an Administrative Law Judge A member or his/her designee may request a hearing before an administrative law judge by writing to: CHDR, the independent review organization that reviewed the member s appeal. CDHR will then forward the request and appeal information to the Administrative Law Judge who will hear the member s appeal. The Health Plan or the local Social Security Administration (SSA) office. This, however, will delay the decision somewhat since the Health Plan or the SSA office will have to forward the appeal to CHDR, as explained above. The member will receive a hearing only if the administrative law judge determines the amount in controversy is $100 or more Review by the Departmental Appeals Board Any party, including the Health Plan, dissatisfied with the decision made by the Administrative Law Judge, may request that the Departmental Appeals Board (DAB) review the ALJ s decision or dismissal. If the Health Plan requests this review, it must notify the member of this action. Upon receiving a request to review an ALJ s decision, the DAB will first decide whether it will agree to review the case. If the DAB determines it will not review the case, the member will be notified and the member may then request a review by a federal court judge (see Section ). Note: The DAB itself may initiate a review within 60 days after the date of an ALJ hearing decision or dismissal. If this occurs, the DAB will mail a notice of this action to all parties involved. A request for a DAB review must be filed within 60 days of the date of receipt of the ALJ s hearing decision or dismissal. (The DAB may extend the time frame for good cause.) Requests must be made in writing and submitted to the DAB at the address given below. Department of Health and Human Services Departmental Appeals Board, MS 6127 Medicare Appeals Council Cohen Building, Room G Independence Avenue, SW Washington, DC Review by Federal Court Judge January 2005

17 Participating Provider Manual 10.0 Medicare Advantage Programs Any party, including the Health Plan, may request judicial review of an ALJ s decision if the DAB denied the party s request for review and the amount in controversy is $1000 or more. To request a judicial review, a party must file a civil action in a district court of the United States in accordance with 205(g) of the Social Security Act (see 20 CFR for a description of the procedures to follow in requesting judicial review). The action should be initiated in the judicial district in which the member lives or in which the Health Plan has its principal place of business Quality Improvement Organization (QIO) Review This section describes quality complaint processes that are separate from the Appeal process described in Section 10.7, above. The Health Plan has agreements with a CMS-approved Quality Improvement Organization (QIO) that conducts reviews required by CMS. A QIO is a group of physicians and health professionals that monitors the quality of care provided to Medicare beneficiaries. The QIO review process is designed to help stop any improper practices. Participating providers shall cooperate with the activities of any CMS-approved QIO in connection with the provision of covered services to members, including providing QIOs with pertinent patient care data such as information on health outcomes and information on Medicare enrollee satisfaction QIO Complaint Process If members are concerned about the quality of care they have received, they may file a complaint with IPRO, the local QIO, at 1(800) January

18 10.0 Medicare Advantage Programs Excellus BlueCross BlueShield QIO Review of Hospital Discharge A member may request an immediate QIO review if the member disagrees with the Health Plan s determination not to cover a continued hospital stay. A QIO review allows members to remain in the hospital without incurring financial liability while the review is being conducted. This review would take the place of the regular appeal process available through the Health Plan, as described in Section 10.7, above. 1. If the member believes he/she is being discharged too soon, the member must ask the hospital or the Health Plan immediately for a written Notice of Discharge and Medicare Appeal Rights (NODMAR), if the member has not received that notice. A member must have the NODMAR if the member wants to exercise the right to request a review by a QIO. 2. A member must request immediate QIO review by noon of the first workday after receiving the NODMAR. Requests are to be made in writing, by telephone or fax to: IPRO 1979 Marcus Avenue First Floor Lake Success, NY IPRO Helpline, NODMAR 1 (800) Fax: (516) TTY: 1(866) A member will not be financially liable for his/her continuing hospital care while the QIO makes its decision. If a member fails to request an immediate QIO review, the member may still request an expedited reconsideration through the Health Plan (see Section 10.7), but the member may be financially liable for the continued hospital care while the reconsideration is being reviewed QIO Review of Termination of Coverage for SNF, HHA or CORF Services A member may request an immediate QIO review if he/she disagrees with the Health Plan s decision that Medicare coverage of services received from a skilled nursing facility (SNF), home health agency (HHA) or comprehensive outpatient rehabilitation facility (CORF) should end. This review would take the place of the regular appeal process available through the Health Plan, as described in Section 10.7, above. 1. Based on provisions of a CMS regulation that went into effect January 1, 2004, SNFs, HHAs and CORFs must provide to members of Medicare Advantage health benefit programs advance Notice January 2005

19 Participating Provider Manual 10.0 Medicare Advantage Programs of Medicare Non-Coverage (NOMNC) no later than two days before the coverage of services will end. Note: See Section 7 of this manual for information regarding the responsibilities of SNFs, HHAs, and CORFs in providing the NOMNC. 2. If, upon receiving such notification, the member decides to appeal the end of coverage, he or she must contact the Quality Improvement Organization (QIO) as soon as possible, but no later than noon of the day before the effective date for services to end. Requests are to be by telephone to: IPRO Helpline, Fast Track Appeal of Advance Notice of Non-Coverage 1 (888) TTY: 1(866) IPRO will make its decision within one full day after receiving the information it needs. If IPRO decides that the Health Plan s decision to terminate coverage was medically appropriate, the member is responsible for paying charges for services after the termination date on the notice received from the provider. If IPRO agrees with the member, the Health Plan will cover the services for as long as medically necessary. If a member misses the deadline for requesting an immediate appeal with the QIO, the member may still request an expedited appeal through the Health Plan (see Section 10.7). If the request does not meet the criteria for an expedited review, the Health Plan will review the decision under its rules for standard appeals. January

20 10.0 Medicare Advantage Programs Excellus BlueCross BlueShield January 2005