Medical care appeals

What is a coverage decision? A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay.

What is an appeal? An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagree with our decision, you can appeal.

Yes. A family member, friend, other trusted person, doctor, or other provider can file the appeal for you. But you must first give them legal permission to act for you. This is called appointing a representative. To appoint a representative, fill out the Appointment of Representative (AOR) form. You can get the form at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf. You must give us a copy of the signed form. You can also call SCFHP Cal MediConnect Plan Customer Service to request a form be mailed to you. Please note that an AOR is valid for one year from the date you and the representative sign the form. You may cancel the appointment of your representative at any time.

SCFHP will also accept an equivalent written notice so long as it includes the following information:

• Your name, address, and telephone number;
• The name, address and telephone number of the person you would like to appoint as your representative;
• Your Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI), or SCFHP Cal MediConnect Plan member ID number;
• Your appointed representative’s professional status or how you are related to him or her (i.e., friend, family member, lawyer, etc.);
• What subject(s) you would like the person to know or speak on (i.e., a complaint, any coverage decision, a medical appeal only, etc.);
• A statement that gives the person permission to act on your behalf and that you allow this person to receive your protected health information (PHI);
• A statement by the person being appointed that he or she accepts the appointment, and
• A signature from you and the representative along with the date you both signed the document.

You may send the completed and signed AOR form or equivalent written notice to:

Attn: AOR Review Team
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

Or fax it to 1-408-874-1965.

Instructions for filling out the AOR can be found on the Member Materials page.

If you or your doctor or other provider disagree with our decision, you can appeal.

In most cases, you must start your appeal at Level 1. If you do not want to first appeal to the plan for a Medi-Cal service, if your health problem is urgent or involves an immediate and serious threat to your health, or if you are in severe pain and need an immediate decision, you may ask for an Independent Medical Review from the Department of Managed Health Care at www.dmhc.ca.gov.

What is a Level 1 Appeal?

A Level 1 Appeal is the first appeal to our plan. We will review our coverage decision to see if it is correct. The reviewer will be someone who did not make the original coverage decision. When we complete the review, we will give you our decision in writing.

If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal.

How do I make a Level 1 Appeal?

• To start your appeal, you, your doctor or other provider, or your representative must contact us.
• You can ask us for a “standard appeal” or a “fast appeal.”
• In a standard appeal, we must give you our answer within 30 calendar days after we get your appeal. We will give you our decision sooner if your health condition requires us to.
• If you ask for a fast appeal, we will give you our answer within 72 hours after we get your appeal. We will give you our answer sooner if your health requires us to do so.

If you are asking for a standard appeal or fast appeal, make your appeal in writing, in person, or call us.

• You can use our online Grievance and Appeal Form to submit a request or print out and complete the Grievance and Appeal Form and mail it to the following address:

Attn: Grievance and Appeals Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

• You may visit the SCFHP Blanca Alvarado Community Resource Center and file your appeal with one of our representatives.

SCFHP Blanca Alvarado Community Resource Center
408 N. Capitol Ave.
San Jose, CA 95133
Business Hours: 10am - 5pm, Monday - Friday

Santa Clara Family Health Plan
6201 San Ignacio Ave.
San Jose, CA 95119
Business Hours: 8:30am - 5pm, Monday - Friday
Customer Service: 1-877-723-4795

• You may also ask for an appeal by calling us at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 am to 8pm

For standard appeals, we will call you or send you a letter within 5 calendar days of receiving your appeal letting you know that we got it.

For fast appeals, we will call you within 24 hours of receiving your appeal letting you know that we got it.

How much time do I have to make an appeal?

You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision.

If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of a good reason are: you had a serious illness, or we gave you the wrong information about the deadline for requesting an appeal. You should explain the reason your appeal is late when you make your appeal.

Can my doctor give you more information about my appeal?

Yes. You and your doctor may give us more information to support your appeal.

How will we make the appeal decision?

We take a careful look at all of the information about your request for coverage of medical care. Then, we check to see if we were following all the rules when we said No to your request. The reviewer will be someone who did not make the original decision. If we need more information, we may ask you or your doctor for it.

What happens next for a standard appeal?

• If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 30 calendar days after we get your appeal (or within 7 calendar days after we get your appeal for a Medicare Part B prescription drug). If your appeal is about payment, we will pay the claim within 60 calendar days.
• If our answer is No to part or all of what you asked for, we will send you a letter. If your problem is about coverage of a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. If your problem is about coverage of a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. For more information about the Level 2 Appeal process, see below.

What happens next for a fast appeal?

• If our answer is Yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal.
• If our answer is No to part or all of what you asked for, we will send you a letter. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity (IRE) for a Level 2 Appeal. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. For more information about the Level 2 Appeal process, see below.

Will my benefits continue during Level 1 appeals?

If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. If you disagree with the action, you can file a Level 1 Appeal and ask that we continue your benefits for the service or item. You must make the request on or before the later of the following in order to continue your benefits:

• Within 10 days of the mailing date of our notice of action; or
• The intended effective date of the action.

If you meet this deadline, you can keep getting the disputed service or item while your appeal is processing.

If the plan says No at Level 1, what happens next?

If we say No to part or all of your Level 1 Appeal, we will send you a letter. This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal.

• If your problem is about a Medicare service or item, we will automatically send your case to Level 2 of the appeals process as soon as the Level 1 Appeal is complete.
• If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. The letter will tell you how to do this. Information is also below.

What is a Level 2 Appeal?

A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan. See the SCFHP Cal MediConnect Plan Member Handbook for detailed information about asking for a Level 2 Appeal. Find a copy of the Cal MediConnect Plan Member Handbook in Member Materials.

An Independent Review Entity (IRE) will carefully review the Level 1 decision and decide whether it should be changed.

• You do not need to request the Level 2 Appeal. We will automatically send any denials (in whole or in part) to the IRE. You will be notified when this happens.
• The IRE is hired by Medicare and is not connected with this plan.
• You may ask for a copy of your file by calling SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

The IRE must give you an answer to your Level 2 Appeal within 30 calendar days of when it gets your appeal (or within 7 calendar days after we get your appeal for a Medicare Part B prescription drug). This rule applies if you sent your appeal before getting medical services or items.

• However, if the IRE needs to gather more information that may benefit you, it can take up to 14 more calendar days. If the IRE needs extra days to make a decision, it will tell you by letter. The IRE can’t take extra time to make a decision if your appeal is for a Medicare Part B prescription drug.

If you had a “fast appeal” at Level 1, you will automatically have a fast appeal at Level 2. The IRE must give you an answer within 72 hours of when it gets your appeal.

• However, if the IRE needs to gather more information that may benefit you, it can take up to 14 more calendar days. If the IRE needs extra days to make a decision, it will tell you by letter. The IRE can’t take extra time to make a decision if your appeal is for a Medicare Part B prescription drug.

My problem is about a Medi-Cal service or item. How can I make a Level 2 Appeal?

There are two ways to make a Level 2 Appeal for Medi-Cal services and items: (1) Independent Medical Review (IMR) or (2) State Hearing.

(1) Independent Medical Review (IMR)

You can file a complaint with or ask for an IMR from the Help Center at the California Department of Managed Health Care (DMHC). By filing a complaint, the DMHC will review our decision and make a determination. An IMR is available for any Medi-Cal covered service or item that is medical in nature. An IMR is a review of your case by doctors who are not part of our plan or a part of the DMHC. If the IMR is decided in your favor, we must give you the service or item you requested. You pay no costs for an IMR.

You can file a complaint or apply for an IMR if our plan:

• Denies, changes, or delays a Medi-Cal service or treatment because our plan determines it is not medically necessary.
• Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition.
• Will not pay for emergency or urgent Medi-Cal services that you already received.
• Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal.

You must apply for an IMR within 6 months after we send you a written decision about your appeal. The DMHC may accept your application after 6 months for good reason, such as you had a medical condition that prevented you from asking for the IMR within 6 months or you did not get adequate notice from us of the IMR process.

To ask for an IMR:

• Fill out the Department of Managed Health Care (DMHC) Independent Medical Review/Complaint Form. Or call the DMHC Help Center at 1-888-466-2219 (TDD: 1-877-688-9891), Monday through Friday, 8 a.m. to 6 p.m.

Or

• Fill out the hard copy IMR application form that is included with the notice you get and send it to:
  
  Help Center
  Department of Managed Health Care
  980 Ninth Street, Suite 500
  Sacramento, CA 95814-2725
  
  Fax: 1-916-255-5241

If you have them, attach copies of letters or other documents about the service or item that we denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents.

If your provider filed an appeal for you, but we do not get your completed Appointment of Representative form or equivalent written notice, you will need to refile your appeal with us before you can file for a Level 2 IMR with the DMHC.

What happens next?

If you qualify for an IMR, the DMHC will review your case and send you a letter within 7 calendar days telling you that you qualify for an IMR. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. You should receive the IMR decision within 45 calendar days of the submission of the completed application.

If your case is urgent and you qualify for an IMR, the DMHC will review your case and send you a letter within 2 calendar days telling you that you qualify for an IMR. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. You should receive the IMR decision within 7 calendar days of the submission of the completed application. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing.

An IMR can take longer if the DMHC does not receive all of the medical records needed from you or your treating doctor. If you are seeing a doctor who is not in your health plan's network, it is important that you get and send us your medical records from that doctor. Your health plan is required to get copies of your medical records from doctors who are in the network.

If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. Your complaint should be resolved within 30 calendar days of the submission of the completed application. If your complaint is urgent, it will be resolved sooner.

(2) State Hearing

You can request a State Hearing for Medi-Cal covered services and items. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, you have the right to ask for a State Hearing.

In most cases you have 120 days to ask for a State Hearing after the "Your Hearing Rights" notice is mailed to you. See the Cal MediConnect Plan Member Handbook for exceptions to this timeframe. Find a copy of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

There are two ways to ask for a State Hearing:

1. You may complete the “Request for State Hearing” on the back of the notice of action. You should provide all the requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. Then you may submit your request one of these ways:

• • The county welfare department at the address shown on the notice.
  • To the California Department of Social Services:
    State Hearing Division
    PO Box 944243, Mail Station 9-17-37
    Sacramento, CA 94244-2430
  • To the State Hearings Division at fax number 1-916-651-5210 or 1-916-651-2789

2. You can call the California Department of Social Services at 1-800-952-5253. TTY users should call 1-800-952-8349. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy.

What happens next?

The State will hold a hearing. You may attend the hearing in person or by phone. You’ll be asked to tell the State why you disagree with our decision. You can ask a friend, relative, advocate, provider, or lawyer to help you. You’ll get a written decision that will explain if you have additional appeal rights.

Will my benefits continue during Level 2 appeals?

If your problem is about a service or item covered by Medicare, your benefits for that service or item will not continue during the Level 2 appeals process with the Independent Review Entity.

If your problem is about a service or item covered by Medi-Cal and you ask for a State Hearing, your Medi-Cal benefits for that service or item can continue until a hearing decision is made. You must ask for a hearing on or before the later of the following in order to continue your benefits:

• Within 10 days of the mailing date of our notice to you that the adverse benefit determination (Level 1 appeal decision) has been upheld; or
• The intended effective date of the action.

If you meet this deadline, you can keep getting the disputed service or item until the hearing decision is made.

How will I find out about the decision?

If your Level 2 Appeal was an Independent Medical Review (IMR), the Department of Managed Health Care (DMHC) will send you a letter explaining the decision made by the doctors who reviewed your case.

• If the IMR decision is Yes to part or all of what you asked for, we must provide the service or treatment.
• If the IMR decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. You can still get a State Hearing. Go to the section above about asking for a State Hearing.

If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision.

• If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision.
• If the State Hearing decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. We may stop any aid paid pending you are receiving.

If your Level 2 Appeal went to the Medicare Independent Review Entity (IRE), it will send you a letter explaining its decision.

• If the IRE says Yes to part or all of what you asked for in your standard appeal, we must authorize the medical care coverage within 72 hours or give you the service or item within 14 calendar days from the date we get the IRE’s decision. If you had a fast appeal, we must authorize the medical care coverage or give you the service or item within 72 hours from the date we get the IRE's decision.
• If the IRE says Yes to part or all of what you asked for in your standard appeal for a Medicare Part B prescription drug, we must authorize or provide the Medicare Part B prescription drug within 72 hours after we get the IRE's decision. If you had a fast appeal, we must authorize or provide the Medicare Part B prescription drug within 24 hours from the date we get the IRE's decision.
• If the IRE says No to part or all of what you asked for, it means they agree with the Level 1 decision. This is called “upholding the decision.” It is also called “turning down your appeal.”

If the decision is No for all or part of what I asked for, can I make another appeal?

If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. Scroll up to the section about asking for a State Hearing for more information.

If your Level 2 Appeal was a State Hearing, you may ask for a rehearing within 30 days after you get the decision. You may also ask for judicial review of a State Hearing denial by filing a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after you get the decision. You cannot ask for an IMR if you already had a State Hearing on the same issue.

If your Level 2 Appeal went to the Medicare IRE you can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. The letter you get from the IRE will explain additional appeal rights you may have.

Refer to SCFHP Cal MediConnect Plan Member Handbook Chapter 9, Section I for more information on additional levels of appeal. Find a copy of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

When you are admitted to a hospital, you have the right to get all hospital services that we cover that are necessary to diagnose and treat your illness or injury.

During your covered hospital stay, your doctor and the hospital staff will work with you to prepare for the day when you leave the hospital. They will also help arrange for any care you may need after you leave.

• The day you leave the hospital is called your “discharge date.”
• Your doctor or the hospital staff will tell you what your discharge date is.

If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay.

Learning about your Medicare rights

Within two days after you are admitted to the hospital, a caseworker or nurse will give you a notice called An Important Message from Medicare about Your Rights. If you do not get this notice, ask any hospital employee for it. If you need help, please call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Read this notice carefully and ask questions if you don’t understand. The Important Message tells you about your rights as a hospital patient, including your rights to:

• Get Medicare-covered services during and after your hospital stay. You have the right to know what these services are, who will pay for them, and where you can get them.
• Be a part of any decisions about the length of your hospital stay.
• Know where to report any concerns you have about the quality of your hospital care.
• Appeal if you think you are being discharged from the hospital too soon.

You should sign the Medicare notice to show that you got it and understand your rights. Signing the notice does not mean you agree to the discharge date that may have been told to you by your doctor or hospital staff.

Keep your copy of the signed notice so you will have the information in it if you need it.

• To look at a copy of this notice in advance, you can call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. You can also call 1-800 MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. The call is free.
• You can also see the notice online at Hospital Discharge Appeal Notices.
• If you need help, please call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. Or call Medicare at the numbers listed above.

Asking us for a Level 1 appeal to change your hospital discharge date

If you want us to cover your inpatient hospital services for a longer time, you must request an appeal. A Quality Improvement Organization will do the Level 1 Appeal review to find out if your planned discharge date is medically appropriate for you. In California, the Quality Improvement Organization is called Livanta Beneficiary and Family Centered Care (BFCC-QIO).

To make an appeal to change your discharge date, call Livanta BFCC-QIO at 1-877-588-1123, available 24 hours a day, 7 days a week. TTY users should call 1-855-887-6668.

Call right away!

Call the Quality Improvement Organization before you leave the hospital and no later than your planned discharge date. An Important Message from Medicare about Your Rights contains information on how to reach the Quality Improvement Organization.

• If you call before you leave, you are allowed to stay in the hospital after your planned discharge date without paying for it while you wait to get the decision on your appeal from the Quality Improvement Organization.
• If you do not call to appeal, and you decide to stay in the hospital after your planned discharge date, you may have to pay all of the costs for hospital care you get after your planned discharge date.
• If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to our plan instead. For details, scroll down to the section on “What happens if I miss an appeal deadline?”
• Because hospital stays are covered by both Medicare and Medi-Cal, if the Quality Improvement Organization will not hear your request to continue your hospital stay, or you believe that your situation is urgent, involves an immediate and serious threat to your health, or you are in severe pain, you may also file a complaint with or ask the California Department of Managed Health Care (DMHC) for an Independent Medical Review.

We want to make sure you understand what you need to do and what the deadlines are.

• Ask for help if you need it. If you have questions or need help at any time, please call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. You can also call the Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-434-0222 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m. Or you can call the Cal MediConnect Ombuds Program at 1-855-501-3077 (TTY:1-855-847-7914), Monday through Friday, 9 a.m. to 5 p.m.

What is a Quality Improvement Organization?

It is a group of doctors and other health care professionals who are paid by the federal government. These experts are not part of our plan. They are paid by Medicare to check on and help improve the quality of care for people with Medicare.

Ask for a “fast review”

You must ask the Quality Improvement Organization for a “fast review” of your discharge. Asking for a “fast review” means you are asking the organization to use the fast deadlines for an appeal instead of using the standard deadlines.

What happens during the review?

• The reviewers at the Quality Improvement Organization will ask you or your representative why you think coverage should continue after the planned discharge date. You don’t have to prepare anything in writing, but you may do so if you wish.
• The reviewers will look at your medical record, talk with your doctor, and review all of the information related to your hospital stay.
• By noon of the day after the reviewers tell us about your appeal, you will get a letter that gives your planned discharge date. The letter explains the reasons why your doctor, the hospital, and we think it is right for you to be discharged on that date. The legal term for this written explanation is called the “Detailed Notice of Discharge.” You can get a sample by calling SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or you can refer to a sample notice here: Hospital Discharge Appeal Notices.

What if the answer is Yes?

• If the Quality Improvement Organization says Yes to your appeal, we must keep covering your hospital services for as long as they are medically necessary.

What if the answer is No?

• If the Quality Improvement Organization says No to your appeal, they are saying that your planned discharge date is medically appropriate. If this happens, our coverage for your inpatient hospital services will end at noon on the day after the Quality Improvement Organization gives you its answer.
• If the Quality Improvement Organization says No and you decide to stay in the hospital, then you may have to pay for your continued stay at the hospital. The cost of the hospital care that you may have to pay for begins at noon on the day after the Quality Improvement Organization gives you its answer.
• If the Quality Improvement Organization turns down your appeal, and you stay in the hospital after your planned discharge date, then you can make a Level 2 Appeal.

Asking for a Level 2 Appeal to change your hospital discharge date

If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make a Level 2 Appeal. You will need to contact the Quality Improvement Organization again and ask for another review.

Ask for the Level 2 review within 60 calendar days after the day when the Quality Improvement Organization said No to your Level 1 Appeal. You can ask for this review only if you stayed in the hospital after the date that your coverage for the care ended.

In California, the Quality Improvement Organization is called Livanta BFCC-QIO. You can reach Livanta BFCC-QIO at 1-877-588-1123 (TTY: 1-855-887-6668), 24 hours a day, 7 days a week.

• Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal.
• Within 14 calendar days of receipt of your request for a second review, the Quality Improvement Organization reviewers will make a decision.

What happens if the answer is Yes?

• We must pay you back for our share of the costs of hospital care you got since noon on the day after the date of your first appeal decision. We must continue providing coverage for your inpatient hospital care for as long as it is medically necessary.
• You must continue to pay your share of the costs, and coverage limitations may apply.

What happens if the answer is No?

• It means the Quality Improvement Organization agrees with the Level 1 decision and will not change it. The letter you get will tell you what you can do if you wish to continue with the appeal process.
• If the Quality Improvement Organization turns down your Level 2 Appeal, you may have to pay the full cost for your stay after your planned discharge date.
• You may also file a complaint with or ask the DMHC for an Independent Medical Review (IMR) to continue your hospital stay. Chapter 9, Section E4 of the SCFHP Cal MediConnect Plan Member Handbook tells how to ask the DMHC for an IMR. Find a copy of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

What happens if you miss an appeal deadline?

If you miss appeal deadlines, there is another way to make Level 1 and Level 2 Appeals, called Alternate Appeals. But the first two levels of appeal are different.

Level 1 Alternate Appeal to change your hospital discharge date

If you miss the deadline for contacting the Quality Improvement Organization (which is within 60 days or no later than your planned discharge date, whichever comes first), you can make an appeal to us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines.

• During this review, we take a look at all of the information about your hospital stay. We check that the decision about when you should leave the hospital was fair and followed all the rules.
• We will use the fast deadlines rather than the standard deadlines for giving you the answer to this review. This means we will give you our decision within 72 hours after you ask for a “fast review.”
• If we say Yes to your fast review, it means we agree that you still need to be in the hospital after the discharge date. We will keep covering hospital services for as long as it is medically necessary.
• It also means that we agree to pay you back for our share of the costs of care you got since the date when we said your coverage would end.
• If we say No to your fast review, we are saying that your planned discharge date was medically appropriate. Our coverage for your inpatient hospital services ends on the day we said coverage would end.
• If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you got after the planned discharge date.
• To make sure we were following all the rules when we said No to your fast appeal, we will send your appeal to the Independent Review Entity. When we do this, it means that your case is automatically going to Level 2 of the appeals process.

Level 2 Alternate Appeal to change your hospital discharge date

We will send the information for your Level 2 Appeal to the Independent Review Entity (IRE) within 24 hours of when we give you our Level 1 decision. If you think we are not meeting this deadline or other deadlines, you can make a complaint. Chapter 9, Section J of the SCFHP Cal MediConnect Plan Member Handbook tells how to make a complaint. Find a copy of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

During the Level 2 Appeal, the IRE reviews the decision we made when we said No to your “fast review.” This organization decides whether the decision we made should be changed.

• The IRE does a “fast review” of your appeal. The reviewers usually give you an answer within 72 hours.
• The IRE is an independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency.
• Reviewers at the IRE will take a careful look at all of the information related to your appeal of your hospital discharge.
• If the IRE says Yes to your appeal, then we must pay you back for our share of the costs of hospital care you got since the date of your planned discharge. We must also continue our coverage of your hospital services for as long as it is medically necessary.
• If this organization says No to your appeal, it means they agree with us that your planned hospital discharge date was medically appropriate.
• The letter you get from the IRE will tell you what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal, which is handled by a judge.

You may also file a complaint with and ask the DMHC for an Independent Medical Review to continue your hospital stay. Chapter 9, Section E of the SCFHP Cal MediConnect Plan Member Handbook tells how to file a complaint and ask the DMHC for an Independent Medical Review. You can ask for an Independent Medical Review in addition to or instead of a Level 3 Appeal.

Find a copy of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

This section is about the following types of care only:

• Home health care services.
• Skilled nursing care in a skilled nursing facility.
• Rehabilitation care you are getting as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are getting treatment for an illness or accident, or you are recovering from a major operation.
• With any of these three types of care, you have the right to keep getting covered services for as long as the doctor says you need it.
• When we decide to stop covering any of these, we must tell you before your services end. When your coverage for that care ends, we will stop paying for your care.

If you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask for an appeal.

How will I know if my coverage is ending?

We will tell you in advance when your coverage will be ending. You will get a notice at least two days before we stop paying for your care. This is called the ”Notice of Medicare Non-Coverage.” This written notice tells you the date we will stop covering your care and how to appeal this decision.

You or your representative should sign the written notice to show that you got it. Signing it does not mean you agree with the plan that it is time to stop getting the care.

When your coverage ends, we will stop paying.

How to ask for a Level 1 Appeal to continue your care

If you think we are ending coverage of your care too soon, you can appeal our decision. This section tells you how to ask for an appeal.

Before you start your appeal, understand what you need to do and what the deadlines are.

• Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do. There are also deadlines our plan must follow. (If you think we are not meeting our deadlines, you can file a complaint. Chapter 9, Section J of the SCFHP Cal MediConnect Plan Member Handbook tells you how to file a complaint. Find a copy of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.)
• Ask for help if you need it. If you have questions or need help at any time, please call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. Or call your State Health Insurance Assistance Program (Health Insurance Counseling & Advocacy Program, or HICAP) at 1-800-434-0222 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m.

During a Level 1 Appeal, a Quality Improvement Organization will review your appeal and decide whether to change the decision we made. In California, the Quality Improvement Organization is called Livanta BFCC-QIO. You can reach Livanta BFCC-QIO at 1-877-588-1123 (TTY:1-855-887-6668), 24 hours a day, 7 days a week. Information about appealing to the Quality Improvement Organization is also in the “Notice of Medicare Non-Coverage." This is the notice you got when you were told we would stop covering your care.

What is a Quality Improvement Organization?

It is a group of doctors and other health care professionals who are paid by the federal government. These experts are not part of our plan. They are paid by Medicare to check on and help improve the quality of care for people with Medicare.

What should you ask for?

Ask them for a "fast-track appeal." This is an independent review of whether it is medically appropriate for us to end coverage for your services.

What is your deadline for contacting this organization?

• You must contact the Quality Improvement Organization no later than noon of the day after you got the written notice telling you when we will stop covering your care.
• If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to us instead. Scroll down to the section about “What happens if I miss an appeal deadline?”
• If the Quality Improvement Organization will not hear your request to continue coverage of your health care services or you believe that your situation is urgent or involves an immediate and serious threat to your health or if you are in severe pain, you may file a complaint with and ask the California Department of Managed Health Care (DMHC) for an Independent Medical Review. Refer to Chapter 9 and Section E4 in your SCFHP Cal MediConnect Plan Member Handbook to learn how to file a complaint with and ask the DMHC for an Independent Medical Review. Find a copy of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

What happens during the Quality Improvement Organization’s review?

• The reviewers at the Quality Improvement Organization will ask you or your representative why you think coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish.
• When you ask for an appeal, the plan must write a letter to you and the Quality Improvement Organization explaining why your services should end.
• The reviewers will also look at your medical records, talk with your doctor, and review information that our plan has given to them.
• Within one full day after reviewers have all the information they need, they will tell you their decision. You will get a letter explaining the decision.

What happens if the reviewers say Yes?

• If the reviewers say Yes to your appeal, then we must keep providing your covered services for as long as they are medically necessary.

What happens if the reviewers say No?

• If the reviewers say No to your appeal, then your coverage will end on the date we told you. We will stop paying our share of the costs of this care.
• If you decide to keep getting the home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date your coverage ends, then you will have to pay the full cost of this care yourself.

How to ask for a Level 2 Appeal to continue your care

If the Quality Improvement Organization said No to the appeal and you choose to continue getting care after your coverage for the care has ended, you can make a Level 2 Appeal.

During the Level 2 Appeal, the Quality Improvement Organization will take another look at the decision they made at Level 1. If they say they agree with the Level 1 decision, you may have to pay the full cost for your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end.

In California, the Quality Improvement Organization is called Livanta BFCC-QIO. You can reach Livanta BFCC-QIO at 1-877-588-1123 (TTY: 1-855-887-6668), 24 hours a day, 7 days a week. Ask for the Level 2 review within 60 calendar days after the day when the Quality Improvement Organization said No to your Level 1 Appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended.

• Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal.
• The Quality Improvement Organization will make its decision within 14 calendar days of receipt of your appeal request.

What happens if the review organization says Yes?

• We must pay you back for our share of the costs of care you got since the date when we said your coverage would end. We must continue providing coverage for the care for as long as it is medically necessary.

What happens if the review organization says No?

• It means they agree with the decision they made on the Level 1 Appeal and will not change it.
• The letter you get will tell you what to do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal, which is handled by a judge.
• You may file a complaint with and ask the DMHC for an Independent Medical Review to continue coverage of your health care services. Chapter 9, Section E4 of the SCFHP Cal MediConnect Plan Member Handbook tells how to ask the DMHC for an Independent Medical Review. You can file a complaint with and ask the DMHC for an Independent Medical Review in addition to or instead of a Level 3 Appeal.

Find a copy of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

What happens if you miss the deadline for making your Level 1 Appeal

If you miss appeal deadlines, there is another way to make Level 1 and Level 2 Appeals, called Alternate Appeals. But the first two levels of appeal are different.

Level 1 Alternate Appeal to continue your care for longer

If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines.

• During this review, we take a look at all of the information about your home health care, skilled nursing facility care, or care you are getting at a Comprehensive Outpatient Rehabilitation Facility (CORF). We check that the decision about when your services should end was fair and followed all the rules.
• We will use the fast deadlines rather than the standard deadlines for giving you the answer to this review. We will give you our decision within 72 hours after you ask for a “fast review.”
• If we say Yes to your fast review, it means we agree that we will keep covering your services for as long as it is medically necessary.
• It also means that we agree to pay you back for our share of the costs of care you got since the date when we said your coverage would end.
• If we say No to your fast review, we are saying that stopping your services was medically appropriate. Our coverage ends as of the day we said coverage would end.

If you continue getting services after the day we said they would stop, you may have to pay the full cost of the services.

Level 2 Alternate Appeal to continue your care for longer

We will send the information for your Level 2 Appeal to the Independent Review Entity (IRE) within 24 hours of when we give you our Level 1 decision. If you think we are not meeting this deadline or other deadlines, you can make a complaint. Click herefor information on making a complaint.

During the Level 2 Appeal, the IRE reviews the decision we made when we said No to your “fast review.” This organization decides whether the decision we made should be changed.

• The IRE does a “fast review” of your appeal. The reviewers usually give you an answer within 72 hours.
• The IRE is an independent organization that is hired by Medicare. This organization is not connected with our plan, and it is not a government agency.
• Reviewers at the IRE will take a careful look at all of the information related to your appeal.
• If the IRE says Yes to your appeal, then we must pay you back for our share of the costs of care. We must also continue our coverage of your services for as long as it is medically necessary.
• If the IRE says No to your appeal, it means they agree with us that stopping coverage of services was medically appropriate.

The letter you get from the IRE will tell you what you can do if you wish to continue with the review process. It will give you details about how to go on to a Level 3 Appeal, which is handled by a judge.

You may also file a complaint with and ask the DMHC for an Independent Medical Review to continue coverage of your health care services. Chapter 9, Section E4 of the SCFHP Cal MediConnect Plan Member Handbook tells how file a complaint with and ask the DMHC for an Independent Medical Review. You can file a complaint with and ask for an Independent Medical Review in addition to or instead of a Level 3 Appeal.

Find a copy of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

You can call us at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

You can get the aggregate number of all grievances, appeals, and exceptions filed with SCFHP Cal MediConnect Plan by contacting the SCFHP Grievance and Appeals Department:

Toll free: 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

Fax: 1-408-874-1962

Write:
Attn: Grievance and Appeals Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

To file a complaint about SCFHP Cal MediConnect Plan to Medicare, click here to use the form on CMS’s website. Or you can call Medicare 24/7 at 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048) to ask for help.

You can ask for published materials for free in other formats, such as large print, Braille, or audio. Call SCFHP Cal MediConnect Plan Customer Service for help.

If you are more comfortable speaking a language other than English, Santa Clara Family Health Plan can help you. Whether you are contacting SCFHP or visiting a doctor, we have interpreters available. Tell your doctor you would like an interpreter for your visit.

Know your rights

• You can get an in-person or telephone interpreter at no cost to you. This includes American Sign Language.
• When you go to the doctor, interpreters are available 24-hours a day.
• You can ask for SCFHP Cal MediConnect Plan materials in English, Spanish, Simplified Chinese, Tagalog, and Vietnamese.

How can you get an interpreter?

Tell your doctor’s office you would like one. You can do this when you call to set up your next visit. You can also ask us for an interpreter or for translated materials.