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What to Do If You Have a Problem or Complaint
 

(Part C Appeals and Grievances)

Asking for a Decision and Making an Appeal
Getting Help Asking for a Decision or Making an Appeal
Asking for a Decision - An Organization Determination
How to Make a Level 1 Appeal
How to Make a Level 2 Appeal
Making a Complaint (also called a grievance)

Your health and satisfaction are important to us. When you have a problem or concern, we hope you’ll try an informal approach first: Please call Member Services. We will work with you to try to find a satisfactory solution to your problem.

You have rights as a member of our Plan and as someone who is getting Medicare. We pledge to honor your rights, to take your problems and concerns seriously, and to treat you with respect.

Sometimes you might need a formal process for dealing with a problem you are having as a member of our Plan.

  • For some types of problems, you need to use the process for initial decisions and making appeals.
  • For other types of problems you need to use the process for making complaints (also called grievances).

Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. Which one do you use? That depends on the type of problem you are having.

(For information about how to ask for a coverage decision or make an appeal regarding your Part D prescription drugs, see section "Part D & Prescription Drugs".)

Asking for a Decision and Making an Appeal

The process for initial decisions and making appeals deals with problems related to your benefits and coverage for medical services, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered.

Asking for Decisions. An organization determination, the initial decision, is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. We make a decision for you whenever you go to a doctor for medical care. You can also contact the Plan and ask for a decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a decision for you.

We are making an organization determination for you whenever we decide what is covered for you and how much we pay:

  • Usually, there is no problem. We decide the service or drug is covered and pay our share of the cost.
  • But in some cases we might decide the service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Making an Appeal. If we make a decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a decision we have made.

When you make an appeal, we review the first decision we have made to check to see if we were being fair and following all of the rules properly. When we have completed the review we give you our decision. If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our Plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal.

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Getting Help Asking for a Decision or Making an Appeal

Here are resources you may wish to use if you decide to ask for any kind of decision or appeal a decision:

  • You can call us at Member Services: 1-888-839-9909 (TTY 1-866-522-2731). LA. Care Health Plan representatives are available 24 hours a day, 7 days a week, including holidays. Fax: 213-623-8974.

    You may send your request in writing to:
    L.A. Care Health Plan
    Attn: Grievance and Appeals Unit
    P.O. Box 712489
    Los Angeles, CA 90071-9998
  • To get free help from an independent organization that is not connected with our Plan, contact your State Health Insurance Assistance Program:
    Health Insurance Counseling and Advocacy Program (HICAP)
    520 S. Lafayette Park Place, Suite 214
    Los Angeles, CA 90057
    1-800-824-0780 or 213-383-4519
    www.calmedicare.org
  • You should consider getting your doctor or other provider involved if possible, especially if you want a “fast” or “expedited” decision. In most situations involving a first decision or appeal, your doctor or other provider must explain the medical reasons that support your request. Your doctor or other provider can’t request every appeal. He/she can request a decision and a Level 1 Appeal with the Plan. To request any appeal after Level 1, your doctor or other provider must be appointed as your “representative” (see below about “representatives”).
  • You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a decision or make an appeal. There may be someone who is already legally authorized to act as your representative under State law. If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services and ask for the form, the Appointment of Representative Form (PDF), to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must give our Plan a copy of the signed form.
  • You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of decision or appeal a decision.

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Asking for a Decision - An Organization Determination

Step 1: You ask our Plan to make a first decision on the medical care you are requesting. If your health requires a quick response, you should ask us to make a “fast decision.”

  • Start by calling, writing, or faxing our Plan to make your request for us to provide coverage for the medical care you want. You, or your doctor, or your representative can do this.
  • When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 14 days after we receive your request.
  • If your health requires it, ask us to give you a “fast decision.” A fast decision means we will answer within 72 hours. If your doctor tells us that your health requires a “fast decision,” we will automatically agree to give you a fast decision.

Step 2: Our Plan considers your request for medical care coverage and we give you our answer.
Generally, for a fast decision, we will give you our answer within 72 hours.

  • If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Generally, for a standard decision, we will give you our answer within 14 days of receiving your request.

  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal.

  • If our Plan says no, you have the right to ask us to reconsider—and perhaps change—this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want.
  • If you decide to make appeal, it means you are going on to Level 1 of the appeals process.

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How to Make a Level 1 Appeal

Step 1: You contact our Plan and make your appeal. If your health requires a quick response, you must ask for a “fast appeal.”

  • To start an appeal you, your representative, or in some cases your doctor must contact our Plan.
  • Make your standard appeal in writing by submitting a signed request.
  • You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for medical care or payment.
  • You can ask for a copy of the information in your appeal and add more information if you like.
  • If you are appealing a decision our Plan made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal.” The requirements and procedures for getting a “fast appeal” are the same as those for getting a “fast decision.” If your doctor tells us that your health requires a “fast appeal,” we will automatically agree to give you a fast appeal.

Step 2: Our Plan considers your appeal and we give you our answer.
When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.

  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours.
  • If our answer is no to part or all of what you requested, we will send you a written notice informing you that we have sent your appeal to the Independent Review Organization for a Level 2 Appeal.

If we are using the standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. We will give you our decision sooner if your health condition requires us to. If your appeal is about payment for services that you have already received, we must give you an answer within 60 calendar days.

  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal.
  • If our answer is no to part or all of what you requested, we will send you a written notice informing you that we have sent your appeal to the Independent Review Organization for a Level 2 Appeal.

Step 3: If our Plan says no to your appeal, your case will automatically be sent on to the next level of the appeals process.

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How to Make a Level 2 Appeal

If our Plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our Plan made when we said no to your first appeal. This organization decides whether the decision we made should be changed.

Step 1: The Independent Review Organization reviews your appeal.

  • If you had a “fast” appeal at Level 1, you will also have a “fast” appeal at Level 2.
  • If you had a “standard” appeal at Level 1, you will also have a “standard” appeal at Level 2.

Step 2: The Independent Review Organization gives you their answer.

  • If the review organization says yes to part or all of what you requested, we must authorize the medical care coverage within 72 hours or provide the service within 14 days after we receive the decision from the review organization.
  • If this organization says no to your appeal, it means they agree with our Plan that your request for coverage for medical care should not be approved. (This is called “upholding the decision.” It is also called “turning down your appeal.”)

Step 3: If your case meets the requirements, you choose whether you want to take your appeal further.
There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).

  • If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. The details on how to do this are in the written notice you got after your Level 2 Appeal.
  • The Level 3 Appeal is handled by an administrative law judge. Chapter 9, Section 9 in the Evidence of Coverage (PDF) tells more about Levels 3, 4, and 5 of the appeals process.

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Making a Complaint (also called a grievance)

The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process.

  • Quality of your medical care
  • Respecting your privacy
  • Disrespect, poor customer service, or other negative behaviors
  • Waiting times
  • Cleanliness
  • Information you get from our Plan
  • Complaints related to the timeliness of our actions related to coverage decisions and appeals

Step 1: Contact us promptly—either by phone or in writing.

You can call us at Member Services: 1-888-839-9909 (TTY 1-866-522-2731). LA. Care Health Plan representatives are available 24 hours a day, 7 days a week, including holidays.

You may fax your request to: 213-623-8974

You may send your request in writing to:
L.A. Care Health Plan
Attn: Grievance and Appeals Unit
P.O. Box 712489
Los Angeles, CA 90071-9998
 

  • Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know.
  • If you do not wish to call, you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here’s how it works: We must address your grievance as quickly as your case requires based on your health status. We may extend the time frame if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.
  • Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 days after you had the problem you want to complain about.
  • If you are making a complaint because we denied your request for a “fast response” to a coverage decision or appeal, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.
  • Since some of your benefits are covered by Medi-Cal, you may also file a grievance with Medi-Cal. For help with your grievance or to complain about your health plan, you may contact the Ombudsman Office of the California Department of Health Care Services at 1-888-452-8609. The Ombudsman Office was created to help Medi-Cal beneficiaries to fully use their rights and responsibilities as a member of a managed care plan. Please refer to your health Plan’s Medi-Cal Evidence of Coverage for more information about how to file a Medi-Cal grievance.

Step 2: We look into your complaint and give you our answer.

  • If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
  • Most complaints are answered in 30 days, but we may take up to 44 days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint.
  • If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

When your complaint is about quality of care, you also have two extra options:

  • You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our Plan). To find the name, address, and phone number of the Quality Improvement Organization in your state, look in Chapter 2, Section 4 in the Evidence of Coverage (PDF). If you make a complaint to this organization, we will work together with them to resolve your complaint.
  • Or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to our Plan and also to the Quality Improvement Organization.

You can make your complaint about the quality of care you received to our Plan by using the step-by-step process outlined above.

For more information about decisions, appeals or complaints, see Chapter 9 in the Evidence of Coverage (PDF). You can also call us at Member Services: 1-888-839-9909 (TTY 1-866-522-2731), 24 hours a day, 7 days a week, including holidays. You may also get help and information from Medicare: 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. www.medicare.gov.

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