Questions about Coverage and Care
All HMOs have member services departments that are designed to assist the plan’s members with a variety of questions about the plan. Questions can be simple—such as what is a member’s co-payment or benefit coverage—or more complex issues including concerns about a selected doctor and how to change providers, the coordination of benefits if both a husband and wife have health coverage through their employers, or the process for appealing a decision made by the doctor or the health plan.
The member services department should be the first place to turn with questions, concerns or problems. The phone number is in your member handbook or on your identification card. Many issues can be easily and quickly resolved. If you are not satisfied with the resolution, you may also file a formal complaint with the plan.
Issues that cannot be resolved by the member services department generally fall into two categories: grievances or utilization review (UR) appeals.
Grievances have to do with non-medical, contractual issues. Utilization review appeals are when a consumer requests that a health plan reconsider its decision to refuse coverage of a medical service based on medical necessity.
While the health plan member services departments may resolve many issues, if you are not satisfied with the resolution, or if you think the issue is not being resolved quickly enough, you may also file a formal “grievance with the plan.”
Every plan must have a grievance and appeals procedure to handle non-medical issues. This includes complaints related to billing problems, benefit coverage issues and issues regarding dissatisfaction with providers or quality of care provided. Some grievances can be filed over the phone, while others must be filed in writing. The health plan will tell you how to file a grievance and what your rights are in the grievance process.
Patients may also have questions relating to the denial of a specific medical treatment, even though the type of treatment may be covered (for example, a plan’s benefits may provide for treatment of cancer, but not stage-one clinical trials). These types of questions are considered utilization review decisions. Your rights concerning decisions on medical issues are covered in more detail in the “utilization review standards” and the Independent External Appeal sections.
For non-medical, contractual issues, every plan’s grievance procedure must include:
- A multi-lingual, accessible toll-free phone line, available at least 40 hours a week. Answering machines may be used during off hours, but your call must be returned within one business day.
- A standard process for filing grievances and appeals and, in certain circumstances, filing verbal grievances.
- Notice of a member’s right to have a representative in the grievance process.
- A process for providing members with a written description of the procedures required to file an appeal when a plan denies a request for service.
- The time-frames for responding to members, including notice of the plan’s receipt of the grievance and grievance determinations.
- Standard time-frames for making a decision on a grievance can be as long as 45 days. But if there is a significant risk to your health, the plan must act within 48 hours.
- The methods for designating qualified reviewers for each grievance, including at least one health care professional for matters of a clinical nature.
- In addition to having processes for filing a grievance, all plans must have a method for making a decision on any and all grievances received.
The following criteria apply to the appeals of grievance determinations:
- Members are provided 60 business days to appeal a grievance decision.
- Clinical determinations must be made by qualified health care professionals not involved with the original decision.
- Non-clinical matters require qualified personnel at a higher level than those who made the initial determination.
- There must be a formal notice of appeals determinations detailing reasons for the determination and the clinical rationale.
Utilization Review Standards
Utilization Review (UR) is a process by which a health plan assesses the medical necessity or appropriateness of health care treatments. These reviews can take place prior to the proposed treatment, during treatment or after the treatment. All plans performing UR are required to:
- Provide notice of an adverse determination (denial of treatment) in writing, including reasons for the determination and instruction on how to appeal.
- Allow the member, or in some cases his/her physician, to appeal a decision involving denied treatment.
- Provide toll-free access to reviewers 40 hours/week. Answering machines may be used during off hours, but your call must be returned within one business day. If you are in the hospital, the plan must be available 24 hours a day, seven days a week to consider a request for an extension of your stay.
- Establish UR time-frames, a member notification system, procedures to appeal determinations and an appeal process.
- Establish an expedited appeal process for members in an ongoing course of treatment and for cases in which the treating physician believes an immediate appeal is warranted.
- Ensure that personnel conducting UR are duly licensed and trained.
- Ensure that a physician or health care professional other than the person who rendered the original decision will review all appeals.
- Provide members with a minimum of 45 days to file an appeal of an adverse determination.
- Make appeal decisions within 60 days and provide written notice of the decision within two business days, giving reasons and the clinical rationale for the determination.
- Ensure that expedited appeals can be further appealed through the regular appeal process.
- Provide expedited appeal determinations within 48 hours of the receipt of appropriate documents related to the case.
Greater detail on all of these requirements is provided in every member’s contract and handbook.