GRIEVANCES, ORGANIZATION DETERMINATIONS and APPEALS

This is a summary of our Grievances, Organization Determinations and Appeals processes.

For step-by-step guidance please refer to the Evidence of Coverage, Chapter 7 What to do if you have a problem or complaint (coverage decisions, appeals, complaints).

DEFINITIONS

AppealAny of the procedures that deal with the review of adverse organization determinations on the health care services an enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the enrollee), or on any amount the enrollee must pay for a service. These procedures include reconsideration by the Medicare health plan and if necessary, an independent review entity, hearings before Administrative Law Judges, review by the Medicare Appeals Council and judicial review.

ComplaintAny expression of dissatisfaction to a Medicare health plan, provider, facility or Quality Improvement Organization (QIO) by an enrollee made orally or in writing. This can include concerns about the operations of providers or Medicare health plans such as: waiting times, the demeanor of health care personnel, the adequacy of facilities, the respect paid to enrollees, the claims regarding the right of the enrollee to receive services or receive payment for services previously rendered. It also includes a plan’s refusal to provide services to which the enrollee believes he or she is entitled. A complaint could be either a grievance or an appeal, or a single complaint could include elements of both. Every complaint must be handled under the appropriate grievances and/or appeals process.

GrievanceAny complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Medicare health plan, provider or facility. An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration timeframe.

In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of health care.

Independent Review Entity

An independent entity contracted by CMS to review Medicare health plans’ adverse reconsiderations of organization determinations.

Organization Determination

Any determination made by a Medicare health plan with respect to any of the following:

Payment for temporarily out of the area renal dialysis services, emergency services, post-stabilization care, or urgently needed services.

Payment for any other health services furnished by a provider other than the Medicare

health plan that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the Medicare health plan.

The Medicare health plan’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by the Medicare health plan.

Reduction or premature discontinuation of a previously authorized ongoing course of treatment:

Failure of the Medicare health plan to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee

Quality Improvement Organization (QIO)Organization comprised of practicing doctors and other health care experts under contract to the Federal government to monitor and improve the care given to Medicare enrollees. QIOs review complaints raised by enrollees about the quality of care provided by physicians, inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare health plans, and ambulatory surgical centers. The QIOs also review continued stay denials for enrollees receiving care in acute inpatient hospital facilities as well as coverage terminations in SNFs, HHAs and CORFs.

Quality of Care IssueA quality of care complaint may be filed through the Medicare health plan’s grievance process and/or a QIO. A QIO must determine whether the quality of services (including both inpatient and outpatient services) provided by a Medicare health plan meets professionally recognized standards of health care, including whether appropriate health care services have been provided and whether services have been provided in appropriate settings.

Reconsideration – An enrollee’s first step in the appeal process after an adverse organization determination; a Medicare health plan or independent review entity may re-evaluate an adverse organization determination, the findings upon which it was based, and any other evidence submitted or obtained.

How to file a Complaint (Grievance) with Colorado Choice Health Plans

Contact Colorado Choice promptly by phone or in writing. Call 719-589-3696 if calling from within the San Luis Valley or 1-800-475-8466 if calling from outside the San Luis Valley. TTY call 1-800-659-2656, 7 days a week, 8:00 am to 8:00 pm, Oct 1 – Feb 14, and Monday through Friday, 8:00 am to 8:00 pm, Feb 15 – Sep 30.

If you do not wish to call (or you called and were not satisfied), you can put your complaint (grievance) in writing and send it to us. If you put your complaint (grievance) in writing, we will respond to your complaint (grievance) in writing.

The complaint (grievance) must be made within 60 days of the event or incident.

Written complaints (grievances) can be sent to:

Colorado Choice Health Plans
700 Main Street, Suite 100
Alamosa, CO  81101

For more information on Complaints (Grievances) see Chapter 7 of the Evidence of Coverage.

ORGANIZATION DETERMINATIONS (Coverage determination)

When a coverage decision involves your medical care, it is called an “organization determination.”

Coverage determinations on medical care

A coverage decision is a decision Colorado Choice Health Plans makes about your benefits and coverage or about the amount we will pay for your medical services. If you disagree with a coverage decision we have made, you can appeal our decision.

Start by calling, writing, or faxing your request for coverage. You, your doctor, or your representative can do this to Colorado Choice Health Plans.

Colorado Choice Health Plans
700 Main Street, Suite 100
Alamosa, Colorado 81101
719-589-3696 or 1-800-475-8466
TTY 1-800-659-2656
FAX: 719-589-4901
ATTN: Customer Service

Making an appeal

If we make a coverage 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 coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

How to make a Level 1 Appeal

You, your representative, or in some cases your doctor must contact our plan.

Start by calling, writing, or faxing our plan to make your request for us to provide coverage for the medical care you want. You, your doctor, or your representative can do this.

Colorado Choice Health Plans
700 Main Street, Suite 100
Alamosa, Colorado 81101
719-589-3696 or 1-800-475-8466
TTY 1-800-659-2656
FAX: 719-589-4901
Attn: Customer Service

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 a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

How to get help when you are asking for a coverage decision or making an appeal

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

You can call Colorado Choice Health Plans at 719-589-3696 or 1-800-475-8466, 8:00 am to 8:00 pm, Monday through Friday. TTY/TDD users should call 1-800-659-2656.

To get free help from an independent organization that is not connected with our plan, contact your State Health Insurance Assistance Program. See Chapter 7 of the Evidence of Coverage. Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision or a Level 1 Appeal on your behalf. To request any appeal after Level 1, your doctor or other provider must be appointed as your representative.

You can have someone to act on your behalf to ask for a coverage decision or make an appeal. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call Customer Service at 719-589-3696 or 1-800-475-8466. TTY/TDD users should call 1-800-659-2656.

AGGREGATE INFO

To obtain an aggregate number of the Plan’s grievances, appeals, and exceptions filed with the plan sponsor, please call or write to Customer Service

CALL: 719-589-3696 or 1-800-475-8466.
TTY/TDD: 1-800-659-2656
FAX:   719-589-4901
WRITE: Colorado Choice Health Plans, 700 Main Street, Suite 100, Alamosa, Colorado 81101.

DISCLAIMER

Colorado Choice Health Plans is a health plan with a Medicare Contract. Enrollment in Colorado Choice’s Medicare cost plan depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information.

Limitations, copayments, and restrictions may apply.

You are eligible to enroll if you are entitled to Medicare Part A and/or enrolled in Medicare Part B and you live in the Colorado Choice Health Plans service area. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. Eligible beneficiaries can enroll in Colorado Choice at any time.

You can use any doctor who is part of Colorado Choice’s network. You may also go to doctors outside of our network. We may not pay for services you receive outside of our network, but Medicare will pay for its share of charges it approves. You will be responsible for paying the Medicare deductible and coinsurance for those services, unless they were authorized in advance by Colorado Choice.

Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits.

Information is available in alternative formats or languages. Please call 1-800-475-8466 (TTY users should call 1-800-659-2656) for details. Se puede presentar la información acerca del plan en un formato o idioma distinto. Para solicitar un documento en español, favor de llamar a Atención al Cliente, al número telefónico indicado debajo.

For more information, contact Customer Service at 719-589-3696 if calling from within the San Luis Valley or at 1-800-475-8466 if calling from outside the San Luis Valley. (TTY users should call 1-800-659-2656). Hours are 8:00 am to 8:00 pm, 7 days a week , Oct 1 – Feb 14, and 8:00 am to 8:00 pm., Monday through Friday, Feb 15 – Sep 30.  (Para asistencia en Español, llame al 719-589-3696 o al 1-800-475-8466).

Information is current as of 6/30/2016. Please contact our Customer Services department to verify that you have the most up to date information.

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