Enrollee Information
FALLON TOTAL CARE- Current Edition 12/2012 2
The following section provides an overview on FTC enrollee rights and responsibilities, appeals and grievances and resources available to FTC providers. Enrollees Rights and Responsibilites: I. Statements of Members Rights and Responsibilities Fallon Total Care (FTC) states the organization s commitment to treating members in a manner that respects their rights as well as its expectations of members responsibilities in its Statements of Members Rights and Responsibilities, which include at least the following: Enrollees Rights A. Each enrollee has the right to be treated with respect and with consideration of their dignity and privacy. B. Each enrollee has the right to be treated fairly regardless of their race, religion, gender, ethnicity, age, disability or source of payment. C. Each enrollee has the right to have their treatment and other member information kept private and confidential. Only where permitted by law, may records be released without the enrollee s permission. D. Each enrollee has the right to easily access care in a timely fashion. E. Each enrollee has the right to receive information on available treatment options and alternatives, presented in a manner appropriate to the Enrollee's condition and ability to understand. F. Each enrollee has the right to share in developing their plan of care. G. Each enrollee has the right to receive interpretation services at no cost to the enrollee, including the right to receive information in a language they can understand. Information is available in alternate formats upon request. H. Each enrollee has the right to receive information about FTC, its practitioners, programs, services, clinical guidelines and role in the treatment process. I. Each enrollee has the right to receive information about clinical guidelines used in providing and managing their care. J. Each enrollee has the right to ask their provider about their work history and training. K. Each enrollee has the right to give input on the FTC s Rights and Responsibilities policy. L. Each enrollee has the right to know about advocacy and community groups and prevention services. M. Each enrollee has the right to request certain preferences in a provider. FALLON TOTAL CARE- Current Edition 12/2012 3
N. Each enrollee has the right to have provider decisions about their care made on the basis of treatment needs. O. Each enrollee has the right to be furnished health care services in accordance with Federal and State laws that pertain to enrollee rights. P. Each enrollee has the right to participate in decisions regarding his or her health care, including the right to receive a second medical opinion, and the right to refuse treatment. Q. Each enrollee has the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation, as specified in Federal regulations on the use of restraints and seclusion. R. Each enrollee has the right to file a complaint/grievance about FTC, a provider or the care received. S. Each enrollee has the right to file an appeal about a FTC action or decision. T. Each enrollee has the right to request and receive a copy of his or her medical records. U. Each enrollee is free to exercise his or her rights, and that the exercise of those rights does not adversely affect the way FTC and its providers treat the enrollee. V. Each enrollee has the right to receive written information on advanced directives and their rights under State law. W. Each enrollee has the right to decline participation or withdraw from programs and services. X. Each enrollee has the right to know which staff members are responsible for managing their services and from whom to request a change in services. Enrollees Responsibilities A. Each enrollee has the responsibility to treat those giving them care with dignity and respect. B. Each enrollee has the responsibility to give providers and FTC information they need. This is so providers can deliver quality care and FTC can deliver appropriate service. C. Each enrollee has the responsibility to ask their providers questions about their care. This is to help them understand their care. D. Each enrollee has the responsibility to follow their treatment plan. The plan of care is to be agreed upon by the enrollee and provider. E. Each enrollee has the responsibility to follow the agreed upon medication plan. F. Each enrollee has the responsibility to tell their providers and primary care physician about medication changes, including medications given to them by others. G. Each enrollee has the responsibility to keep their appointments. Enrollees should call their provider(s) as soon they know they need to cancel visits. FALLON TOTAL CARE- Current Edition 12/2012 4
H. Each enrollee has the responsibility to let their provider know when the treatment plan is not working for them. I. Each enrollee has the responsibility to report abuse and fraud. Callers may choose to remain anonymous. All calls will be investigated and remain confidential. J. Each enrollee has the responsibility to openly report concerns about quality of care. II. Provider Education The Statements of Member Rights and Responsibilities are distributed to practitioners in FTC s Provider Manual and available on the FTC website. Copies are also readily available to practitioners upon request. FTC does not restrict providers from advising or advocating on their patients behalf. III. Member Education The Statements of Rights and Responsibilities are distributed to new and existing members in FTC s Evidence of Coverage manual, member newsletter and website. Copies are also readily available to members, authorized representatives, customer organizations and the general public upon request. FTC recognizes the specific needs of members and maintains a mutually respectful relationship with members. IV. Review and Revisions The Statements of Rights and Responsibilities are revised when necessary to fulfill requirements of CMS, the state s statutes, or to satisfy public concern in specific issues. Review and revisions to the Statements are the responsibility of FTC s Quality Programs Department to ensure compliance with external regulatory agencies and comply with FTC s policy regarding Member Rights and Responsibilities. FALLON TOTAL CARE- Current Edition 12/2012 5
ENROLLEE MEMBER APPEALS AND GRIEVANCES PROCESS Fallon Total Care supports the rights of Enrollees and providers acting on the Enrollee s behalf to file a grievance about plan policies, providers or services and to appeal an adverse determination made by the plan regarding their coverage or service. This section describes the Fallon Total Care processes in place to support the filing of such and the procedures for providers to advocate on the Enrollee s behalf or to guide Enrollees regarding their rights to request an appeal or grievance. CUSTOMER SERVICE The Fallon Total Care Customer Service Department is available to assist Enrollees and Enrollee prospects with their service needs. The direct telephone number is 1-855-508-3390. TTY access for those who are hearing impaired is TRS relay 711. The Customer Service Department assists customers with routine inquiries such as questions regarding benefits, ID card requests and PCP selections (see section on Access services ). The Customer Service staff can also assist Enrollees with more complex needs such as administrative discrepancies and difficulties with obtaining access to care. More complex cases are documented to ensure follow-through and a record for future reference. On some occasions, you may be contacted by a member of the Customer Service staff for assistance with servicing an Enrollee. The Customer Service staff also works closely with the Fallon Total Care Enrollee Appeals and Grievances Department to make sure that Enrollees wishing to file a grievance or appeal are handled in an appropriate fashion. The Customer Service Department can also assist you with urgent Enrollee eligibility questions. All routine eligibility questions that cannot be resolved by reviewing your panel report should be directed to Customer Service at 1-855-508-3390. All routine requests will be responded to within one business day. If you or your office staff has questions regarding prior authorization or case management claims for all your FTC Enrollees, you can contact the Provider Service Line at TBD to be directed to the appropriate department. ENROLLEE APPEALS AND GRIEVANCES DEPARTMENT APPEALS AND GRIEVANCE PROCEDURES Fallon Total Care s Enrollee Appeals and Grievances Department Coordinators are available to assist Enrollees if they have grievances about plan policies, providers or services, or wish to appeal an adverse determination made by the plan regarding their coverage or service. FALLON TOTAL CARE- Current Edition 12/2012 6
Coordinators are trained to assist Enrollees with their grievances and appeals in accordance with their rights and in a confidential manner. The staff follows policies and procedures which protect Enrollee rights and adhere to quality standards set by the National Committee for Quality Assurance (NCQA), the duals under 65 contract, Medicare guidelines as defined by the Centers for Medicare & Medicaid (CMS) and all Federal and State requirements, including 42. Subpart M and C.F.R. 422 Subpart M and 42 C.F.R 438. Fallon Total Care utilizes the following definitions: Grievance: An Enrollee s written or oral expression of dissatisfaction with any aspect of operations, activities or behavior of an ICO, or its providers regardless of whether remedial action is requested. Appeal: a request by an Enrollee to review any ICO decision to deny, terminate, suspend, or reduce services. An Enrollee may appeal a delay in the ICO providing or arranging for a Covered Service. The Enrollee Appeals and Grievances Department has dedicated staff to promote Enrollee retention, to make every effort to satisfy Enrollee expectations and strengthen customer confidence. When any Fallon Total Care Enrollee is dissatisfied with plan policy, plan providers or services, they have a right to file a grievance. Enrollee Appeals and Grievances coordinators work with Fallon Total Care providers or management staff to review and resolve the grievance. The standard for resolving all Enrollee grievances is 30 calendar days. All grievance data is tracked to report trends, corrective action plans and improvement measures to FTC. ENROLLEE APPEALS AND GRIEVANCES When plan Enrollees are dissatisfied with the outcome of a plan review regarding denial of coverage or services, they have the right to appeal the decision. The Enrollee Appeals and Grievances staff coordinates the plan s Enrollee appeals procedure for FTC. GRIEVANCES A grievance is the type of complaint an Enrollee may make if he/she has any other type of problem with Fallon Total Care or one of our plan providers. If the grievance is made by someone other than the Enrollee, the Enrollee must submit a document appointing him or her to act on their behalf. The Enrollee, or the person you choose to represent him/her, would file a grievance if there was a problem with situations such as: Waiting times when filling a prescription The way the network pharmacist or others behave Being able to reach someone by phone Getting the information needed FALLON TOTAL CARE- Current Edition 12/2012 7
The cleanliness or condition of a network pharmacy Whenever we do not provide a fast decision about an initial request for a service or a request to appeal FTC s denial of a service. There are two kinds of grievances you can file: 1. Expedited (72 hours) An Enrollee may file an expedited grievance whenever FTC does not provide a fast decision about an initial request for a service or a request to appeal a denial of a service. 2. Standard (30 days) An Enrollee may file a standard grievance. FTC will contact the Enrollee within 30 calendar days of receiving the grievance to discuss a possible resolution to the concern. Expedited Grievance Call the Fallon Total Care Enrollee Services Department at: 1-855-508-3390 (TTY users, please call TRS Relay 711). Monday through Friday, from 8 a.m. to 6 p.m. (Expedited grievances can be made and are processed 24 hours a day, seven days a week by leaving a voice message.) Fax: TBD Standard Grievance Call the Fallon Total Care Enrollee Services Department at the number below or, send a letter including all details of your grievance to: Fallon Total Care 10 Chestnut St. Worcester, MA 01608 TBD, Monday through Friday, from 8 a.m. to 6 p.m. Fax: TBD A Fallon Total Care Enrollee Services Representative will let you know that FTC received a letter within 24 to 48 hours of receipt. Every reasonable attempt will be made to resolve the complaint within 30 days. All grievances submitted in writing will be responded to in writing. Grievances made orally will be responded to orally and in writing. All quality of care grievances will be responded to in writing and will include information of the rights to file a written complaint to the Quality Improvement Organization. APPEALS Standard Appeals Process The Enrollee or Authorized Appeal Representative may appeal if he/she does not agree with health plan s decisions about medical bills or services. The Enrollee must submit the appeal request within 60 days of receipt of the health plan s initial determination notice. FALLON TOTAL CARE- Current Edition 12/2012 8
The health plan must process the appeal and notify the Enrollee of its determination in writing as expeditiously as the Enrollee s health requires but no later than within 30 calendar days of receipt of the appeal request. If the health plan does not rule fully in favor of the Enrollee, the entire case file must be forwarded to the MAXIMUS, CMS contracted agency, within the above specified time frame. An Enrollee may also request a hearing from the MassHealth BOH for an External Appeal regarding Medicare services. For Behavioral Health Diversionary Services, Dental services and LTSS, an Enrollee may only appeal to the BOH. An Enrollee using the BOH process may request aid pending Appeal for services that have been prior authorized at the time of filing for the duration of the Appeal process, provided that the Enrollee appeals within 10 calendar days of the date of mailing of FTC s Internal Appeal decision. FTC will be bound by the IRE or BOH ruling, or subsequent ruling, that is most favorable to the Enrollee. An Enrollee may file the appeal: On his or her own behalf; or By giving someone (family Enrollee, friend, physician/practitioner, etc.) permission to act on his or her behalf. If a Enrollee chooses to give someone permission to act on his or her behalf during the Internal Appeal, FTC requires the Enrollee to sign and return a Personal Representative Authorization form. This person is referred to as the Enrollee s Authorized Appeal Representative. Please note for Expedited Internal Appeals, the physician/treating provider can file an expedited appeal on the Enrollee s behalf and act as the Authorized Appeal Representative without written authorization from the Enrollee being received prior to processing the Expedited Appeal Request. The Personal Representative Authorization form can be obtained by calling the FTC Enrollee Appeals & Grievances Department at TBD, Monday through Friday from 8:00 a.m. to 5:00 p.m. If FTC does not receive this form by the time the deadlines expire for resolving the Standard Internal Appeal, FTC will notify the Enrollee in writing that their Standard Internal Appeal has been dismissed. If the Enrollee believes that he or she did in fact submit the Personal Representative Authorization form within the standard Internal Appeal deadlines, the Enrollee can request that the dismissal be reversed by sending a letter to FTC within ten (10) calendar days of the dismissal. FTC will consider the request and will decide to either reverse the dismissal and continue with the Appeal or will uphold its dismissal. FTC will notify the Enrollee of this decision in writing. If FTC upholds the Enrollee s dismissal, the dismissal will become final. If the Enrollee disagrees with this decision, the Enrollee can Appeal to the Executive Office of Health and Human Services, Office of Medicaid s Board of Hearings (BOH). FALLON TOTAL CARE- Current Edition 12/2012 9
FTC provides Enrollees with one level of Standard Internal Appeal review and one level of Expedited Internal Appeal review. The Enrollee or Authorized Appeal Representative has the right to file an Internal Appeal if they disagree with one of the following actions or inactions by FTC: FTC denied or decided to provide limited authorization for a service requested by the Enrollee s health care provider. FTC reduced, suspended or terminated a service covered by FTC that FTC previously authorized. FTC denied, in whole or in part, payment for an FTC covered service due to service coverage issues. FTC did not decide a standard or expedited service authorization request within the required timeframes. A Enrollee was unable to obtain health care services within the time frames described in the how long should one wait to see a doctor section of this Enrollee Handbook. Note: This includes behavioral health services. An Enrollee or Authorized Appeal Representative may file an Internal Appeal over the telephone, in writing, in person or via e-mail or fax; which includes: Calling FTC s Enrollee Appeals & Grievances Department at: TBD, (TDD/TTY: 1-877-608-7677), Monday through Friday from 8:00 a.m. to 5:00 p.m. Sending a letter describing the request to: Fallon Total Care 10 Chestnut St. Worcester, MA 01608 Attn: Enrollee Appeals & Grievances Department Presenting the request, in person, Monday through Friday from 8:00 a.m. to 5:00p.m. at: Fallon Total Care 10 Chestnut St. Worcester, MA 01608 Sending an e-mail to: TBD Faxing a detailed letter to: TBD When an Enrollee or Authorized Appeal Representative files an Internal Appeal, it should include: 1. Enrollee s name. 2. Enrollee s FTC plan identification number (located on the FTC Enrollee ID card). 3. The facts of the request. Please note, an Enrollee or Authorized Appeal Representative can present evidence and allegation of fact or law in person or in writing during the Appeals process by contacting the Enrollee Appeals & Grievances Coordinator at TBD, Monday through Friday, 8 a.m. to 5 p.m. This information must be received by FTC prior to the review of the Appeal or final decision. 4. Information about the outcome that the Enrollee or Authorized Appeal Representative wants. FALLON TOTAL CARE- Current Edition 12/2012 1
5. The name of any FTC representative that either the Enrollee or Authorized Appeal Representative may have spoken to. 6. A request for an Expedited Internal Appeal if the Enrollee or Authorized Appeal Representative thinks the Enrollee s condition requires this level of Appeal. To ask for help with any of the Appeal process options, call the FTC Enrollee Appeals & Grievances Department at TBD Monday through Friday from 8:00 a.m. to 5:00 p.m. (TTY users, please call TRS Relay 711). Remember that, if necessary, FTC can assist an Enrollee or Authorized Appeal Representative with interpreter services during the Internal Appeal process. Filing a Standard or Expedited Internal Appeal An Enrollee or Authorized Appeal Representative may file a Standard or Expedited Internal Appeal within thirty (30) calendar days of FTC s notice that informs the Enrollee about any action or inaction that entitles the Enrollee or Authorized Appeal Representative to an Internal Appeal. But, if the Enrollee did not receive such a notice, the Internal Appeal request must be filed within thirty (30) calendar days of learning on his/her own about FTC s actions or inactions described above. If the Internal Appeal request is received more than sixty (60) calendar days after the denial letter notifying the Enrollee of the action that the Enrollee or Authorized Appeal Representative are appealing (or, if the Enrollee did not receive a denial notice thirty (30) calendar days from the date he/she learned of the action or inaction), FTC will dismiss the Internal Appeal and will notify the Enrollee and Authorized Appeal Representative in writing that the Appeal has been dismissed. If the Enrollee or Authorized Appeal Representative believes that he/she did in fact submit the Internal Appeal within the deadlines, the Enrollee or Authorized Appeal Representative can request that the dismissal be reversed by sending a letter to FTC within ten (10) calendar days of the dismissal. FTC will consider the request and will decide either to reverse the dismissal and continue with the Appeal or will uphold its dismissal. FTC will notify the Enrollee and Authorized Appeal Representative of this decision in writing. If FTC upholds the dismissal, the dismissal will become final and the request will be forwarded to Maximus. How the Standard Internal Appeal process works FTC will process the Appeal as quickly as the Enrollee s health requires and will notify the Enrollee and Authorized Appeal Representative of our decision no later than thirty (30) calendar days from the date the Standard Internal Appeal request is received unless an extension is taken as described in the following section. Obtaining a Standard Internal Appeal Extension FALLON TOTAL CARE 7
1. If the Enrollee or Authorized Appeal Representative wants to send FTC more information regarding the Appeal, the Enrollee or Authorized Appeal Representative may request an extension of up to fourteen (14) calendar days to have more time to obtain the information. 2. FTC may also take an extension of up to fourteen (14) calendar days to obtain necessary information. 3. Please note that FTC can only request an extension if: The extension is in the best interest of the Enrollee FTC needs additional information that we believe, if we receive it, will lead to approval of the Enrollee or Authorized Appeal Representative s request Such outstanding information is reasonably expected to be received within fourteen (14) calendar days. If the Enrollee or Authorized Appeal Representative does not agree with the extension taken by FTC, the Enrollee or Authorized Appeal Representative may file a Grievance. For more information about Grievances, refer to the Grievances section described above. FTC utilizes a coordinated Appeals process that will ensure Enrollees have access to all Medicaid and Medicare Appeals processes. If, on internal Appeal, FTC does not decide in the Enrollee s favor, FTC will automatically forward Medicare services to the CMS Independent Review Entity (IRE), Maximus Federal Services. The Enrollee may also request a hearing from the MassHealth Board of Hearings. 72-hour Appeals Process If the Enrollee or his/her physician believes that his/her health, life, or ability to regain maximum function could be adversely affected without a particular service, the Enrollee or Authorized Appeal Representative may appeal the denial of coverage for that service through the 72-hour appeal process. Note: 72-hour appeal requests may be made either orally or in writing. The health plan must make a decision to accept or deny the request for the expedited appeal. If the decision is to deny the request for an expedited appeal, the health plan must notify the Enrollee of this decision in writing within 72 hours of the initial request and process the request through the standard appeals process. NOTE: If any physician requests a 72-hour appeal on behalf of an Enrollee, the health plan must accept the request. If the health plan accepts the request for an expedited appeal, the health plan must make a decision to approve or deny coverage for the requested service and notify the Enrollee in writing of this decision as expeditiously as the Enrollee s health requires, but no later than within 72 hours of the initial request. Under certain circumstances, the health plan may take an additional 14 calendar days to make a decision if the extension of time benefits the Enrollee (e.g. additional consultation or FALLON TOTAL CARE 8
testing is necessary or the health plan is waiting for the receipt of outside records). If the health plan does not rule fully in favor of the Enrollee, the entire case file must be forwarded to the MAXIMUS, CMS contracted agency, within 24 hours of the health plan s decision. MAXIMUS will render a determination. An Enrollee may also request a hearing from the MassHealth BOH for an External Appeal regarding Medicare services. For Behavioral Health Diversionary Services, Dental services and LTSS, an Enrollee may only appeal to the BOH. An Enrollee using the BOH process may request aid pending Appeal for services that have been prior authorized at the time of filing for the duration of the Appeal process, provided that the Enrollee appeals within 10 calendar days of the date of mailing of FTC s Internal Appeal decision. FTC will be bound by the IRE or BOH ruling, or subsequent ruling, that is most favorable to the Enrollee. How to request an Expedited Internal Appeal If the Enrollee or Authorized Appeal Representative wants to request an Expedited Internal Appeal and if the Appeal does not apply to denials of payment: 1. File the Appeal over the telephone, in writing, in person, via e-mail or fax. 2. The Enrollee or Authorized Appeal Representative should clearly state the request by stating, I want a fast Appeal, or I believe that the Enrollee s health could be seriously harmed by waiting 30 calendar days for a normal Appeal. How the Expedited Internal Appeal process works If the Enrollee meets the qualifications for an Expedited Internal Appeal, FTC will process the Appeal request and let the Enrollee and Authorized Appeal Representative know of our decision orally and in writing, as quickly as the Enrollee s health requires, but not later than 72 hours from when we received the request. Getting an Expedited Internal Appeal Extension 1. If the Enrollee or Authorized Appeal Representative wants to send us additional information that s important to the Appeal, the Enrollee or Authorized Appeal Representative may request an extension of up to fourteen (14) calendar days. 2. FTC may also make an extension of up to fourteen (14) calendar days only if: The extension is in the best interest of the Enrollee FTC needs additional information that we believe, if we receive it, will lead to approval of the request. Such outstanding information is reasonably expected to be received within fourteen (14) calendar days. If the Enrollee or Authorized Appeal Representative does not agree with the extension taken by FTC, the Enrollee or Authorized Appeal Representative may file an Expedited Grievance. For more information about Grievances, refer to the Grievances section described above. If the Enrollee or Authorized Appeal Representative s request does not qualify for an Expedited Internal Appeal: FALLON TOTAL CARE 9
1. The Appeal request will be processed within the time frame for a standard Internal Appeal of as expeditiously as the Enrollee s health requires, but not more than thirty (30) calendar days. 2. The Enrollee and Authorized Appeal Representative will be notified, in writing, that the Appeal request will be handled as a Standard Internal Appeal. 3. If the Enrollee or Authorized Appeal Representative disagrees with this decision, they may file a Grievance. For more information about Grievances, refer to the Grievances section described below. FTC utilizes a coordinated Appeals process that will ensure Enrollees have access to all Medicaid and Medicare Appeals processes. If, on internal Appeal, FTC does not decide in the Enrollee s favor, FTC will automatically forward Medicare services to the CMS Independent Review Entity (IRE), Maximus Federal Services. The Enrollee may also request a hearing from the MassHealth Board of Hearings. Request a hearing for a Board of Hearings Appeal The Enrollee or Authorized Appeal Representative can request a hearing from the Executive Office of Health and Human Services, Office of Medicaid s Board of Hearings (BOH) if: 1. The Enrollee or Authorized Appeal Representative is dissatisfied with the FTC Expedited Internal Appeal determination; or 2. The Enrollee or Authorized Appeal Representative is dissatisfied with the FTC First- Level Standard Internal Appeal. To do so, the Enrollee or Authorized Appeal Representative needs to complete the Fair Hearing Request form which he/she will receive with the Appeal determination letter and mail or fax it to the following address: Executive Office of Health and Human Services Office of Medicaid Board of Hearings 2 Boylston St. Boston, MA 02116 Or, fax to TBD The Enrollee or Authorized Appeal Representative must file the Fair Hearing Request Form within thirty (30) calendar days of FTC s decision resolving his/her Internal Appeal. To ask for help with any of the Appeal process options, call the FTC Enrollee Appeals & Grievances Department at TBD (TTY users, please call TRS Relay 711). Board of Hearings: Expedited Internal Appeal If the Appeal was an Expedited Internal Appeal and the Enrollee or Authorized Appeal Representative wants BOH to make an Expedited decision too, the Enrollee or Authorized Appeal Representative must request a BOH Appeal within thirty (30) calendar days of FTC s decision resolving the Expedited Internal Appeal. FALLON TOTAL CARE 10
How to receive continuing services If the Enrollee or Authorized Appeal Representative wants to receive continuing coverage of previously authorized services through the outcome of the BOH Appeal, the request must be received by the BOH within ten (10) calendar days of FTC s decision resolving the Internal Appeal. The Enrollee or Authorized Appeal Representative also has the option of canceling these services. Reviewing the Appeal File Before or during the Appeals process, the Enrollee or Authorized Appeal Representative can request to review the case file, including medical records and any other documentation or records that FTC considered during the Appeal process. FALLON TOTAL CARE 11