Legal

Appeals and Grievance Process for Medicare Part C Summary Information

MEDICAL SERVICES AND BENEFITS

YOUR RIGHT TO APPEAL

You can appeal if you do not agree with Network Health Insurance Corporation’s decisions about your health care. You must file your appeal in writing or orally within 60 calendar days after the date of the denial. We can give you more time if you have a good reason for missing the deadline.

You have the right to appeal if you believe the following.

  • Network Health Insurance Corporation will not approve care it should cover.
  • Network Health Insurance Corporation is stopping care you still need.
  • Network Health Insurance Corporation has denied payment for services or items you have received that are not covered and you think they should be covered.

WHO MAY FILE AN APPEAL?

You or someone you name to act for you (called your representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor or someone else to act for you. Also, others may be authorized under State law to act for you.

To learn how to name your representative, you
can call us at 800-378-5234 (TTY 800-947-3529), Monday–Friday, 8 a.m. to 8 p.m. From October 1–March 31, we’re here every day, 8 a.m. to 8 p.m.

If you want someone to act for you, you and the person you choose must sign, date and send us a statement naming that person to act for you.

HOW DO I FILE AN APPEAL?

To file an appeal, you can call us at 800-378-5234 (TTY 800 947-3529), Monday–Friday, 8 a.m. to 8 p.m. From October 1–March 31, we’re here every day, 8 a.m. to 8 p.m. Or, you can send it to us in writing by faxing to 920-720-1832 or mailing to:

Network Health Insurance Corporation

Attn: Appeals and Grievance Department

P. O. Box 120

Menasha, WI 54952

THERE ARE THREE KINDS OF APPEALS

1. A Standard Pre-Service Appeal (Also known as a Reconsideration) (30 days)

If your request is for medical coverage or services that you haven’t received yet, you can ask for a standard appeal. We must give you a decision no later than 30 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.)

2. A Fast Appeal (72 hour review)

You can ask for a fast appeal on services that you haven’t received yet if you or your doctor believe that your health could be seriously harmed by waiting too long for a decision. We must decide on a fast appeal no later than 72 hours 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.)

  • If any doctor asks for a fast appeal for you, or supports you in asking for one, and the doctor indicates that waiting for 30 days could seriously harm your health, we will automatically give you a fast appeal.
  • If you ask for a fast appeal without support from a doctor, we will decide if your health requires a fast appeal. If we do not give you a fast appeal, we will decide your appeal within 30 days.
  • We will make a decision on your appeal and notify you within the above timelines. However, if our decision is not fully in your favor, we will automatically forward your appeal request to the CMS contractor (MAXIMUS Federal Services) for an independent review. MAXIMUS will send you a letter with their decision within three working days of receipt of your case from Network Health Insurance Corporation.

3. A Standard Request for Payment Appeal (60 days)

If your request is for payment of services you already received, you can ask for a standard appeal. We must give you a decision no later than 60 days after we get your appeal.

INFORMATION TO SUBMIT TO SUPPORT YOUR APPEAL

You are not required to submit additional information to support your request for services or payment for services already received. Network Health Insurance Corporation is responsible for gathering all necessary medical information, however, it may be helpful to you to include additional information to clarify or support your position.

For example, you may want to include in your appeal request information such as medical records or physician opinions in support of your appeal. To obtain medical records, send a written request to your Primary Care Physician. If your medical records from specialist physicians are not included in your medical record from your Primary Care Physician, you may need to make a separate written request to the specialist physician(s) who provided medical services to you.

WHAT HAPPENS NEXT?

If you submit an appeal to Network Health, we will complete a full and fair review to determine if our original denial of the requested services or payment for services can be changed. After we complete our review, we will notify you of our decision. If our decision is not in your favor, we will automatically forward your appeal request to the CMS Contractor (MAXIMUS Federal Services) for an independent review. This is provided by Medicare for a new and impartial review of your case outside of your Medicare Advantage organization. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.

HOW DO I FILE A GRIEVANCE?

If you’re dissatisfied with the service or quality provided by your plan or doctor, we’re here to work with you through any issues. You have the right to file a grievance (a formal complaint) about how Network Health, our vendors or contracted providers provided services.

  • Examples of situations appropriate for a grievance include the following.
  • Difficulty getting through on the phone
  • Concerns about the quality of care of services provided
  • Interpersonal aspects of care (for example, rudeness of a provider or staff)
  • Failure to respect your rights

You can submit a grievance over the phone or in writing within 60 calendar days from the date of the event. You can call us at 800-378-5234
(TTY 800-947-3529), Monday–Friday from 8 a.m. to 8 p.m. From October 1–March 31, we’re available every day, 8 a.m. to 8 p.m. Or, you can send it to us in writing by faxing to 920-720-1832 or mailing to:

Network Health Insurance Corporation

Attn: Appeals and Grievance Department

P. O. Box 120

Menasha, WI 54952

We will complete an investigation of your grievance as quickly as your case requires and send you a letter about this no later than 30 calendar days from the date we received your request. If we need more time to investigate the situation, we’ll let you know about that extension prior to the end of the initial 30-day period.

Coverage Determinations, Exceptions, Appeals and Grievance Procedures for Medicare Part D

SUMMARY INFORMATION

PRESCRIPTION DRUG BENEFITS

Whenever you ask for a Part D prescription drug benefit coverage determination, the first step is called “requesting a coverage determination.” When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. You must contact Express Scripts, Inc. at 800-316-3107 (TTY 800-899-2114), 24 hours a day seven days a week, if you would like to request a coverage determination. You cannot request an appeal if we have not issued a coverage determination.

There are two types of coverage determinations; standard or fast. A decision about whether we will cover a Part D prescription drug can be a standard coverage determination. This is made within the standard time frame of 72 hours. You can only request a fast decision if you or your doctor believes that waiting for a standard decision could seriously harm your health or your ability to function. Fast decisions apply only to requests for Part D drugs that you have not received yet. For a fast decision, we will give you our decision within 24 hours or sooner if your health requires.

EXCEPTIONS

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make, such as:

  • Asking us to cover your drug even if it is not on our formulary
  • Asking us to waive coverage restrictions or limits on your drug
  • Asking us to provide a higher level of coverage for your drug

If you request an exception, your physician must provide a statement to support your request. Generally, we will only approve your request for an exception if the alternative drugs included in the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition, and you are still enrolled in Network Health’s Medicare Advantage plan. If we deny your exception request you can appeal our decision.

WHAT IS A GRIEVANCE? (PART D)

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have a problem with Network Health Insurance Corporation’s Medicare Advantage pharmacy plans or one of our network pharmacies that relates to coverage for a prescription drug.

For example, you would file a grievance if you have a problem with things such as:

  • Waiting times when you fill a prescription
  • The way your network pharmacist or others behave
  • Not being able to reach someone by phone or get the information you need
  • The cleanliness or condition of a network pharmacy

If you have a grievance, we encourage you to first call customer service at the number listed in your Evidence of Coverage. We will try and resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you.

You can submit a grievance over the phone or in writing within 60 calendar days from the date of the event. You can call us at 800-378-5234 (TTY 800-947-3529), Monday–Friday from 8 a.m. to 8 p.m. From October 1–March 31, we’re available every day, 8 a.m. to 8 p.m. Or, you can send it to us in writing by faxing to 920-720-1832 or mailing to:

Network Health Insurance Corporation

Attn: Appeals and Grievance Department

P. O. Box 120

Menasha, WI 54952

APPEAL (ALSO CALLED A REDETERMINATION)

If you are unhappy with the coverage determination, you can ask for an appeal. You may also appeal our decision:

  • Not to cover a drug, vaccine or other Part D benefit
  • Not to reimburse you for a Part D drug that you paid for
  • If you think we should have reimbursed you more than you received or if you are asked to pay a different cost-sharing amount than you think you are required to pay
  • If we deny your exception request

You must send your appeal to Network Health in writing within 60 calendar days after the date of the denial. We can give you more time if you have a good reason for missing the deadline, such as being in the hospital.

THERE ARE TWO KINDS OF APPEALS

Standard Appeal

If your request is about reimbursement for a Part D drug you already paid for and received, or about a part D drug that has been denied, you can ask for a standard appeal. We must give you a decision no later than seven (7) calendar days from the date we receive your appeal, but will make it sooner if your health condition requires us to. If we do not give you our decision within seven calendar days, your request will automatically go to the second level of appeal where an independent organization will review your case.

Fast Appeal

You can ask for a fast appeal if you or your doctor believe that your health could be seriously harmed by waiting too long for a decision. We must decide on a fast appeal no later than 72 hours after we get your appeal, but will make it sooner if your health requires us to. If we do not give you our decision within 72 hours, your request will automatically go to the second level of appeal, where an independent organization will review your case.

If any doctor asks for a fast appeal for you, or supports you in asking for one, and the doctor indicates that waiting for seven calendar days could seriously harm your health, we will automatically give you a fast appeal. If you ask for a fast appeal without support from a doctor, we will decide if your health requires a fast appeal. If we do not give you a fast appeal, we will decide your appeal within seven calendar days.

If we deny any part of your appeal, you or your representative have the right to ask for an independent review organization to review your case. This independent review organization contracts with the federal government and is not part of Network Health Insurance Corporation Medicare Advantage pharmacy plans. You must make your request for review by the independent review organization in writing within 60 calendar days after the date you were notified of the decision on your first appeal. You must send your written request to the independent review organization whose name and address is included in the level 1 redetermination.

HOW TO FILE AN APPEAL OR GRIEVANCE (PART D)

This document provides summary details about your appeal and grievance rights. You will obtain the full procedures when you enroll in Network Health’s Medicare Advantage plan.

If you have questions about the appeal or grievance process, you can call us at 800-378-5234 (TTY 800-947-3529),  Monday–Friday from 8 a.m. to 8 p.m. From October 1–March 31, we’re available every day, 8 a.m. to 8 p.m. Or, you can send it to us in writing by faxing to 920-720-1832 or  mailing to:

Network Health Insurance Corporation

Attn: Appeals and Grievance Department

P. O. Box 120

Menasha, WI 54952

Medicare Ombudsman

The Medicare website for the Office of the Medicare Ombudsman (OMO) can help you with complaints, grievances and information requests.


Network Health
1570 Midway Place
Menasha, WI 54952
Hours
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.