HEALTHY GENERATIONS
Part C (Medical) Grievance and Appeals Process
For problems about prescriptions or pharmacies, please go to the Part D (prescription drug) Grievance and Appeals Process
We encourage you to let us know right away if you have questions, concerns, or problems related to your coverage or the care you receive. We are always ready to help you solve any problems you have about your care. We will try to resolve any complaint that you might have over the phone. If we cannot resolve your complaint over the phone, we have formal procedures to review your complaints. We call this our Grievance and Appeals process.
A complaint will be handled as a grievance or appeal depending on the subject of the complaint. We will respond to your concerns quickly as possible through our Grievance and Appeals process, which is detailed below and provided in Sections 10 and 11 of your Healthy Generations Evidence of Coverage booklet.
Grievances
A grievance is a type of complaint you make if you are dissatisfied with SCFHP or our doctors for reasons other than a coverage decision. For example, you would file a grievance if you have a problem with such things as the quality of medical care you received, waiting time for appointments, or the way your doctor or others behave or the cleanliness or condition of your doctor’s office. Complete details of the grievance process can be found in your Healthy Generations Evidence of Coverage booklet under Section 10 “How to file a grievance”.For a complaint about coverage or payment for care problems about being discharged from the hospital too soon, and problems about coverage for Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation (CORF) services ending to soon you need to file an Appeal.
Grievance Process
You may have another person, such as your doctor, lawyer or family member request a grievance on your behalf. The person you name would be your appointed representative. If you would like to appoint a representative to assist you with the grievance process, you can print the appointed representative form, fill it out and mail or fax it to us at:
SCFHP
Attn: Grievance and Appeals Department
Fax: 408-874-1962 Attn: Grievance and Appeals Department
If you submit a written grievance, you will get an answer in writing. If you submit a verbal grievance, you will get an answer by telephone, unless you ask for an answer in writing. All quality of care grievances will be answered in writing.
There are two kinds of grievances that you can request:
Fast Grievance (24 hour): You, any doctor, or your appointed representative can ask for a fast grievance if you disagree with SCFHP’s decision not to give you a fast decision on a medical care issue, or if you disagree with our decision to take a time extension on an initial decision or appeal. We will respond to this type of grievance by telephone, within 24 hours from the time that we received your complaint and within three calendar days you will receive a written letter.
Standard Grievance (30 days) is any other type of complaint. We must respond to you within as promptly as your medical condition requires, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.
If you are concerned about the quality of care you received, you can also send your complaint to Santa Clara Family Health Plan (SCFHP) or the Quality of Improvement Organization (QIO), an independent review organization, or both. The QIO is called Lumetra. Complaints to Lumetra must be in writing to the following address:
Lumetra
Attention: Beneficiary Services
Fax: 415-677-2179
Your grievance
will be reviewed by SCFHP’s Grievance Committee. The Grievance Committee will decide how to
resolve your grievance. You have the right
to come to the Grievance Committee meeting.
If you
don’t accept the resolution of SCFHP’s Grievance Committee, you may ask SCFHP’s
Governing Board to review the Grievance Committee’s decision. This means SCFHP’s Governing Board will
review and talk about your case and decide if the resolution the Grievance
Committee gave you should be changed.
You may tell SCFHP in person, by telephone, in writing or through
SCFHP’s internet website that you want to “appeal the grievance decision”.
How do I file a
grievance?
You or your appointed representative may file a grievance within 60 days of the event or incident by telephone, mail, fax or in person to:
Phone: 1-800-260-2055 Monday
through Friday 8:00 am to 8:00 pm.
Mail: SCFHP
Attn: Grievance and Appeals Department
Fax: 408-874-1962, Attn: Grievance and Appeals Department
In Person: SCFHP
Internet: Visit SCFHP’s website at http://www.scfhp.com
to fill out a Member Grievance Form
For a standard grievance you or your appointed representative should call, mail, or deliver your grievance request to the address/numbers above.
For fast grievances you or your appointed representative should contact us by telephone or fax to the numbers above.
Appeals
An appeal is the type of complaint that you make when you
want SCFHP to reconsider and change a decision that has been made about what
medical services or benefits are covered for you or what we will pay for a
service or benefit. For example, if we
will not cover or pay for services that you think we should cover, you can file
an appeal. If you think we are stopping
the coverage of a medical service or benefit too soon, you can file an
appeal. For complaints that are not
related to coverage decisions, you need to file a Grievance.
Appeal Process
You may have another person, such as your doctor, lawyer or family member request an appeal on your behalf. The person you name would be your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your representative. You can print the appointed representative form, fill it out and mail it to us at:
SCFHP
Attn: Grievance and Appeals Department
Fax: 408-874-1962
If you disagree with our decision, you have the right to appeal it within 60 days from the date of our denial notice. We can give you more time if you have a good reason for missing the deadline.
There are five levels of the appeal process:
Appeal Level 1: If we deny any part or all of your request to cover or pay for service a you or your appointed representative may ask us to reconsider or “appeal” our decision. There are two kinds of appeals that you can file:
Standard Appeal: You, your doctor or appointed representative may ask for a standard appeal regarding providing medical care or payment for care.
For a decision about payment for care you already received, SCFHP will give you a decision no later than 60 days after we get your appeal. We may extend this time by up to 14 days if you request an extension or if we need additional information and the extension benefits you.
For a decision about medical care we will give you a decision within 30 calendar days, but will make it sooner if your health condition requires. However, if you request, or if we find that some information is missing which can help you, we can take up to 14 more days to make our decision.
Fast Appeal: You, any
doctor, or your representative can ask us to give a fast appeal. We will give you decision about your medical
care within 72 hours after you or your doctor ask for it--sooner if your health
requires.
· If any doctor asks for a fast appeal for you, or supports you in asking for one, and the doctor indicates that waiting 30 days could seriously harm your health, SCFHP will automatically give you a fast appeal.
·
If you or your appointed representative asks for
a fast appeal without support from a doctor, SCFHP will review your
request. If we do not grant your request
for a fast appeal, we will send you a letter within three calendar days notifying
you that we will make our decision within the standard timeframe of 30 calendar
days. The letter will also tell you how
to file a grievance if you disagree with our decision to deny your request for
a fast appeal, and will explain that we will automatically give you a fast
decision if you get a physician’s support for a fast appeal.
How do I file an
Appeal with SCFHP?
For a standard appeal you or your appointed representative should mail or deliver your written appeal to:
SCFHP
Attn: Grievance and Appeals Department
For a fast appeal, you or your appointed representative should contact Member Services by telephone at 1-800-260-2055 or fax your request to 408-874-1962, Attention: Grievance and Appeals Department.
You should include your name, address, member ID number, reason for appealing and any evidence that you wish to attach. You may include supporting medical records, doctors’ letters, or other information that explains why we should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person to the fax number or address above.
Appeal Level 2: If we deny any part of your first appeal, your appeal automatically goes on to Appeal Level 2 where an independent review organization (IRE) will review your case. The independent review organization has no connection to SCFHP. We will tell you in writing that your appeal has been sent to this organization for review. For complete details and further explanation of the appeal process, please review Section 11 “Information on how to make a complaint about Part C Medical Services and Benefits” of the Healthy Generations Evidence of Coverage booklet.
Appeal Level 3: If the organization that reviews your case in Appeal Level 2 does not rule completely in your favor, you or your appointed representative may ask for a review by an administrative law judge in writing within 60 days after the date you were notified of the decision made at Appeal Level 2. The administrative law judge will not review your appeal if the dollar value of the medical care is less than $110.
Appeal Level 4: If you get a denial at Appeal Level 3, you or your appointed representitive can request review by filing a written request with the Medicare Appeals Council. The letter that you get from the administrative law judge will tell you how to contact the Council.
Appeal Level 5: To request a juridical review of your case, you must file a civil action in a United States District Court. The letter you get from Medicare Appeal Council in Appeal Level 4 will tell you how to request this review. The judge’s decision is final and you may not take the appeal any further.