Medical Coverage Decisions & Appeals

If we deny a prior authorization request, payment request, or other request for a Medicare-covered medical service, you have the right to ask us to review our decision.

This page explains medical coverage decisions, appeals, and your rights as an Elderplan member.

What Is a Medical Coverage Decision?

A medical coverage decision (also called an organization determination) is a decision we make about your Medicare-covered medical care, services, or items.

Examples include decisions about:

• Prior authorization requests
• Medical services
• Durable medical equipment (DME)
• Skilled nursing care
• Home health services
• Medicare Part B drugs
• Payment for services you have already received

If you disagree with a medical coverage decision, you may have the right to appeal.

What Is an Appeal?

An appeal is a formal request asking us to review a decision we made about coverage or payment.

You may request an appeal if:

• A prior authorization request was denied
• A service was approved for less than what was requested
• A request for coverage was denied
• Payment for a service was denied

You, your authorized representative, or your provider may request an appeal on your behalf.

Medicare Appeals Process

There are several levels in the Medicare appeals process.

Level 1: Reconsideration

Reconsideration is the first level of appeal.

When we receive your appeal, we conduct a new review of the original decision and any information submitted in support of your request.

Need a Faster Decision?

You may request an expedited appeal if waiting for a standard decision could seriously jeopardize your health, your life, or your ability to regain maximum function.

If your provider supports the request for a faster review, we will expedite the appeal.

Level 2: Independent Review

If we uphold our original decision, your appeal is automatically forwarded to an Independent Review Entity (IRE).

The IRE is an independent organization that is not affiliated with Elderplan and reviews the case to determine whether the original decision should be upheld or overturned.

Additional Appeal Levels

Depending on the type of request and the amount in controversy, additional appeal rights may be available, including:

• Administrative Law Judge (ALJ) review
• Medicare Appeals Council review
• Federal Judicial Review

Information about available appeal rights will be included in your appeal decision notice.

How Long Does an Appeal Take?

In certain situations, we may extend the timeframe if additional information is needed and the extension is in your best interest.

Filing a Complaint (Grievance)

A complaint — also called a grievance — is different from an appeal. You file an appeal when you disagree with a decision we made about coverage or payment. You file a grievance when you have a concern about the quality of your care or the way the plan is serving you, such as:

• The quality of care you received from a provider
• Customer service, wait times, or trouble reaching us
• Conditions at a facility
• Our decision to take extra time to make a coverage decision or appeal
• Our decision not to give you a fast (expedited) coverage decision or appeal

You, or someone you appoint to act on your behalf, can file a grievance within 60 calendar days of the event. You can call Member Services or send your complaint in writing.

We respond to most grievances within 30 calendar days. If your complaint is about our decision not to expedite a request, or about taking extra time, we respond within 24 hours.

For concerns about the quality of your care, you may also contact the Quality Improvement Organization for New York, Commence Health (formerly Livanta). You can file with us, with the Quality Improvement Organization, or both.

File a Complaint Directly With Medicare

You can file a complaint directly with Medicare at any time. Use the Medicare.gov complaint form, or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.

Appointing a Representative

You have the right to appoint a family member, friend, attorney, physician, or another individual to act on your behalf during the appeals process.

An Appointment of Representative form may be required.

Need Help Filing an Appeal?

Member Services can help answer questions about medical coverage decisions, prior authorization denials, and the appeals process.