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What are Appeals and Grievances?

You have the right to make a complaint if you have concerns or problems related to your coverage or care. Appeals and grievances are the two different types of complaints you can make.

Appeal

An Appeal is the type of complaint you make when you want us to reconsider and change a decision we have made about what services are covered for you or what we will pay for.

  1. A Medical Director Appeal may be filed when you are not satisfied with a Presbyterian Medical Director decision that either denied or limited a medical service.
  2. An Initial Appeal Review may be filed when you are not satisfied with any other Presbyterian decision that was not made by a Medical Director, and did not deny or limit a medical service. Example: How Presbyterian paid a claim.
  3. A Fast (Expedited) Appeal may be requested only when it is an emergency medical issue. This type of appeal is for those cases in which a longer time to reach a decision may increase the medical risk to the Member. This does not apply to issues such as the request to change a decision regarding how a claim was paid. Your appeal request may be submitted in writing or may be submitted verbally by calling the Presbyterian Customer Service Center (PCSC) at 1-800-797-5343 or TTY/TDD users should call 711 or 1-800-659-8331. Fast Appeal Requests may also be submitted by calling the Appeals department at 505-923-6060 or toll free at 1-800-797-5343, Monday through Sunday 8 am to 8 pm. Fast appeals may also be faxed to 505-923-5124.

How to file an Appeal

Initial Appeals: You may call PCSC to start the appeal process or you may send a letter to the Appeals Coordinator. Presbyterian must receive the Member's appeal request within 60 days of the action or decision that is being appealed. You may contact PCSC at 505-923-6060 or toll-free, 1-800-797-5343 or TTY/TDD users should call 711 or 1-800-659-8331, with any questions. The appeal request should clearly explain the nature of the Appeal. You should include any of the following that you feel may help your appeal: medical records, medical literature, medical bills, expense records, and written statements or letters from you or a healthcare Provider.

You can submit a written appeal request letter to:

Grievance and Appeals Coordinator
P.O. Box 27489
Albuquerque, NM 87125-7489

Or Fax to: 505-923-5124

You may also submit your appeal electronically


Grievance

A grievance is the type of complaint you make if you have any other type of problem with Presbyterian Senior Care (HMO) or Presbyterian MediCare PPO or one of our plan practitioners and providers. For example, you would file a grievance if you have a problem with things such as the quality of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor's office.

How to file a Grievance:

If you have a complaint, we encourage you to first call PCSC at 505-923-6060 or toll-free, 1-800-797-5343 or TTY/TDD users should call 711 or 1-800-659-8331, Monday through Sunday 8:00 am to 8:00 pm with any questions. We will try to resolve any complaint that you might have over the phone, or, you may submit a written complaint. We have a formal procedure to review your complaints. We call this our formal grievance process. Once we receive your grievance, Presbyterian Health Plan will write you to let you know how we have addressed your concern within fifteen (15) working days after we receive your grievance. In some instances, we may need additional time to address your concern. If additional time is needed, we will keep you informed of how your grievance is being handled. No matter which process you use to notify Presbyterian Health Plan, we must keep track of all grievances or complaints in order to report our data to CMS and to our members, upon request.

You may send your grievance request letter to:

Grievance and Appeals Coordinator
P.O. Box 27489
Albuquerque, NM 87125-7489

Or Fax to: 505-923-5124

You may also submit your grievance electronically


Coverage Determination Decisions

A coverage determination 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 a doctor or if your network doctor refers you to a medical specialist.

You or your doctor can contact us and ask for a coverage determination 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 determination decision for you.

We are making a coverage determination decision for you whenever we decide what is covered for you and how much we will pay for the medical service. In some cases we might decide that a service or drug is not covered or is no longer covered under your plan. If we make a coverage determination decision and you are not satisfied with the 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.

How to get help with a coverage determination

Would you like some help? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:

  1. You can call PCSC at 505-923-6060 or toll-free 1-800-797-5343
  2. To get free help from an independent organization that is not connected with our plan, contact your State Health Insurance Assistance Program
  3. Your doctor can make a request for you.
    • For medical care, your doctor can request a coverage decision or a Level 1 Appeal on your behalf. If your appeal is denied at Level 1, it will be automatically forwarded to Level 2. To request any appeal after Level 2, your doctor must be appointed as your representative.
    • For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or a Level 1 or Level 2 Appeal on your behalf. To request any appeal after Level 2, your doctor or other prescriber must be appointed as your representative.
  4. 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, call our customer service center and ask for the "Appointment of Representative" form. The form is also available on the Centers for Medicare & Medicaid Services
    • The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.
  5. You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision.

Medicare Plan Documentation of Appeal and Grievance Processes

The Evidence of Coverage/Member Handbook explains benefits, rights, responsibilities, and other important information for new and current members of Presbyterian Medicare Plans.

Evidence of Coverage (EOCs)

For complete information about Exceptions, Grievances, Appeals, and Coverage Determinations see the Evidence of Coverage for each Plan we offer:

Presbyterian Senior Care (HMO)


Appointment of Representative

A party may appoint a representative if he or she wants assistance with their appeal. A physician or supplier may act as a beneficiary's appointed representative. A party may appoint a representative to act on his or her behalf by completing Form CMS-1696, Appointment of Representative (AOR), which is available on the CMS website.

A party may also appoint a representative through a submission that meets the following requirements:

  • It is in writing and is signed and dated by both the party and the individual who is agreeing to be the representative;
  • It includes a statement appointing the representative to act on behalf of the party and if the party is a beneficiary, authorizing the adjudicator to release identifiable health information to the appointed representative;
  • It includes a written explanation of the purpose and scope of the representation;
  • It contains the name, telephone number, and address of both the party and the appointed representative;
  • If the party is a beneficiary, the beneficiary's Medicare HIC number;
  • It indicates the appointed representative's professional status or relationship to the party; and
  • It is filed with the entity that is processing the party's initial determination or appeal.

A representative may submit arguments, evidence, or other materials on behalf of the party. The representative, the party, or both may participate in all levels of the appeals process. Once both the party and the representative have signed the AOR Form, the appointment is valid for one year from the date of the last signature for the purpose of filing future appeals unless it has been revoked.

As noted above, a beneficiary may also assign (transfer) his or her appeal rights to a physician or supplier who is not a party to the initial determination and who furnished the items or services at issue in the appeal. A beneficiary must assign appeal rights using the form CMS-20031, Transfer of Appeal Rights, available on the CMS website.

A physician or supplier who accepts assignment of appeal rights must waive the right to collect payment from the beneficiary for the items or services at issue in the appeal, with the exception of deductible and coinsurance amounts and when a valid Advance Beneficiary Notice is in effect per Medicare Physician Guide: Chapter 7, Inquiries, Overpayment, and Appeals. Pg 4-5.

Medicare members may submit a complaint or appeal directly to Medicare

If you are a Medicare beneficiary, you may contact PCSC to request an aggregate report of Medicare member complaints received by our plan.

 

For information on Pharmacy Exceptions, click here

 
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Last Updated: 09/30/2016