Managed Healthcare Systems Authorisation programmes and Claims management Member Information: MHS Appeals and Grievance Procedures 1. What is a Funding decision? A decision about whether a medical service, procedure or drug prescribed for the member is funded by the option and the amount, if any the member will be required to pay for the service or prescription. 2. What is an appeal? A request from a member or member s authorised representative to review an adverse benefit or funding determination. This includes services related to coverage, which includes benefit exclusions, non-covered benefits and decisions related to the medical necessity and/or appropriateness of a health care service. This also includes full or partial adverse benefit determinations involving a requested health care service or claim. It is a process by which a member or member s authorised representative (or provider on behalf of member) with the written consent of the member may file a written appeal regarding the denial of payment of a health care service on the basis of medical necessity and appropriateness. An appeal may be filed regarding a decision that: Disapproves full or partial payment for a requested health care service; Approves the provision of a requested health care service for a lesser scope or duration than requested; or Disapproves payment for the provision of a requested health care service but approves payment for the provision of an alternative health care service. 3. What is a grievance or complaint? It is a type of complaint the member, doctor or representative makes about the managed care organisation, medical scheme, service providers or pharmacies, including complaints 1
concerning poor service delivery, or the quality of care. This type of complaint does not involve coverage or payment disputes. 4. The procedure to submit an appeal There are two types of provider and member appeals to be used under differing circumstances: An expedited appeal is used when a member is receiving an on-going treatment or service or is scheduled to receive a service for which coverage has been denied and the seriousness of the circumstances require that the appeal be reviewed quickly because the physician believes that the lack of service will adversely affect the member s health. We acknowledge expedited appeals immediately by telephone, if possible. This process may be used when any of the following circumstances exist: A delay in decision making might jeopardise the member s life, health or ability to regain maximum functions based on a prudent layperson s judgment and confirmed by the treating practitioner; or In the opinion of the practitioner with knowledge of the member s medical condition would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. Concerning the admission, continued stay or other health care services for a member who has received emergency services, but has not been discharged from a facility; or Concerning a concurrent review. A standard appeal is used under all other circumstances, including denials resulting from retrospective reviews of services rendered without the required authorisation. Step Action 1 Prospective (standard & expedited)/concurrent/ Urgent Appeals netcare.appeals@mhs.co.za wcmas.appeals@mhs.co.za primecure.appeals@mhs.co.za Retrospective Appeals A service provider or member has 120 days from the date of the initial denial of coverage in which to file an appeal (or dispute). netcare.appeals@mhs.co.za wcmas.appeals@mhs.co.za primecure.appeals@mhs.co.za 2 The MHS case manager communicates any additional information 2
necessary to conduct the review. The service provider or member gathers the information and forwards it in writing to the relevant e-mail address. The appeal needs to have: A written appeal by the member or member representative, Member information: scheme, option, member number and dependant code; Clear statement of the decision against which the appeal is being submitted; The urgency of the appeal e.g. standard, expedited, urgent appeal; A letter of motivation from the service provider; and Substantiating clinical information, e.g. radiology, pathology reports, photographs, completion of standardised MHS forms etc. 3 The information is escalated to the appeals committee. Within 30 calendar days of receipt of all pertinent information, the clinical appeals committee who was not involved in the original decision reviews the case and communicates the decision back to the MHS case manager in writing. For urgent appeals (see below *) this process is completed within 72 hours. The appeals committee will decide whether to reverse or uphold the original decision. 4 MHS sends a written and/ or provides verbal telephonic notification of the decision to the: Appealing service provider; General Practitioner, if appropriate; Facility, if appropriate; Member and/or the member s representative 5 The communication includes: The decision on the case; Principal reasons and clinical rationale. 6 The authorisation, depending on the decision will either be granted, partially granted, funding for alternative course of treatment authorised or denied. 7 Comprehensive notes are to be made on the HOD system in the additional comments section. 8 Savings reason if applicable is to be added. 9 Should the member not be satisfied with the outcome of their appeal their next recourse would be to submit a complaint to the Council for Medical 3
Schemes. * Urgent Appeals A request for an urgent review of a previous adverse benefit determination for medical, pharmaceutical, or behavioural health services based on medical necessity and appropriateness, filed by a member, member s authorised representative or a provider with the members written consent, when: A delay in decision making might jeopardise the member s life, health, or ability to regain maximum function or when supported by a doctor with knowledge of the claimants medical condition; Concerning the admission, continued stay or other health care services for a member who has received emergency services, but has not been discharged from a facility; or Concerning a concurrent review. Verbal and written notification will be made to the member or his/ her service provider or representative within seventy two (72) hours from receipt of the request. Note: if a life-threatening emergency situation exists it would normally fall under PMB s definition of emergency or other PMB groups and the scheme would be compelled to fund such treatment. Requests from providers may be received either verbally or in a written format. Provider requests will be accepted as expedited requests, but would need to be substantiated with clinical information. Should a member submit the same type of request, it would be required that the service provider submit a Letter of Motivation (LOM) and providing supporting clinical information in the form of radiology/ pathology reports, photographs etc. The following e-mail addresses may be used to submit complaints: Netcare Medical Scheme: complaints@netcaremedicalscheme.co.za WCMAS: wcmas@wcmas.co.za Prime Cure: escalations@primecure.co.za The complaint needs to comply with the following: Can be in a written format or verbal telephonic complaint, 4
Member information: scheme, option, member number and dependant code; Clear statement of the reason for the complaint. Feedback with respect to the complaint and resolve must be provided within 30 calendar days of receipt of the complaint, but optimally should be dealt with within 72 hours from receipt. 5. Confidentiality and Discrimination All grievances and appeals are handled in a confidential manner. Members can be assisted by MHS case managers in their own language should they have difficulty in understanding the process. 5