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Grievance or Appeals

A grievance is a written or verbal request to reconsider a plan decision. A subscriber grievance form is given to you upon your request. This form includes the same information about the grievance and appeals process you will find listed below. You are asked to fill out the form and return it to the Preferred Care Service Recovery Administrator. You may write a letter explaining the problem rather than filling out the form.

If the grievance is received verbally, Preferred Care will begin processing it right away. A copy will be sent to you to review, change if necessary, and sign. Access to a clinical peer reviewer is available within one (1) business day of notice of the grievance.

In cases where a grievance has not been satisfactorily resolved, you will have the
following options:

• The first step is to grieve or appeal the decision. The grievance may be submitted verbally or in writing.
• If you disagree with the grievance decision, the next step (except for appeals related to medical necessity) is to file a formal appeal with Preferred Care.

You may assign a representative to handle your grievance and/or appeal. You may file your dispute either verbally or in writing. For more information, Contact Member Services. If you call after hours, please leave a message. Member Services will return your call within one (1) business day.

The Service Recovery Administrator will determine the qualified individual(s) to review your dispute after the grievance or appeal has been received.

• Any dispute that is based on a clinical issue or a medical adverse determination will require a medical director or other qualified clinician to join in the review
  and/or processing of your dispute.
• If the dispute deals with an administrative, benefit, or service issue, the Service Recovery Administrator may review it with additional Preferred Care staff.
• On second level non-clinical disputes, the Service Recovery Administrator will review the dispute with staff at a higher level. These individuals will not have been involved in the original determination of the grievance.
  

You may ask for a copy of the plan materials, medical criteria, internal policy, guidelines, procedure, or rule used to make this decision.

• You have 180 calendar days from the date of the initial denial to file a grievance. You may file your dispute either verbally or in writing.
• If a grievance is received verbally, the form is completed by Member Services and mailed to you to review, change if necessary, and sign. If the grievance is received verbally, Preferred Care will begin processing it right away.

• You will be notified that the grievance form has been received within five (5) business days after Preferred Care receives the form. A notice is sent to you if additional information is needed. You have 45 calendar days to provide the requested information. The notice will include the name, address, and telephone number of the person you may contact with questions.

The Service Recovery Administrator collects copies of all relevant information including denied claims, records, and letters. Any individual that was involved in the initial denial will not take part in the grievance decision. This includes medical personnel. A decision will be made within 15 calendar days for all pre-service decisions (prior to treatment being received) after the grievance is received. Post-service decisions (after treatment is received) will be made thirty (30) calendar days for after the grievance is received.

• A written notice of the grievance outcome will be sent to you within three (3) business days of the decision. The notice will include how the outcome was decided and how to access further appeal rights, if necessary. The notice will include the name, address and telephone number of a person for you to contact with questions.
• All denial notices will have a medical basis for the decision and any further appeal rights you may have.

If you wish to exercise your right to a formal appeal, complete and return an appeal form to the Service Recovery Administrator.

Grievances

A. Expedited grievances for issues other than medical necessity

Preferred Care has an expedited process to handle grievances as quickly as possible. This process is used when a delay would put your health in danger.

• A decision is made within 48 hours after the appeal was received.
• You will be notified of the outcome verbally within 24 hours and in writing within three business days. The notice will include a reason for the decision and explain any further appeal rights. The notice also will include a form for filing an appeal. It also will include the name, address, and telephone number of an appropriate contact person.
• All notices of denials will include the medical basis for the decision and any further appeal rights you may have.

B. Grievances due to denials based on medical necessity

If your grievance is due to a denial based on medical necessity, the request for review skips the grievance process. It becomes an appeal right away.

Appeals

A. Appeals for issues other than medical necessity

You may appeal the decision if the grievance outcome is not acceptable to you.

• An appeal must be in writing and contain your signature.
• You have 60 business days from the date you were notified of the grievance outcome to return the appeal. Appeal forms are available from Member Services. If the appeal is received verbally, a form is completed and mailed to you to review, change if necessary, and sign. The process starts right away if an appeal is received verbally.
• You are notified that the appeal form has been received within five (5) business days from the receipt of the form. You are also notified if additional information is needed. You have 45 calendar days to provide that information. The notice will include the name, address, and telephone number of a person you may to contact with questions.
• The appeal will be reviewed by qualified individual(s) who did not participate in the original denial or grievance.
• A decision on your appeal will be made within 15 calendar days for all pre-service (prior to treatment being received) decisions after the appeal was
  received. Post-service (after treatment is received) decisions will be made within thirty (30) calendar days after the appeal was received.
• You may schedule a time to present an appeal in person or by phone. The presentation must be within the timeframe set by State and Federal regulations.
  Appeal decisions are made based on information and documentation available within the set timeframe.

All available data is used to make a decision. This includes your testimony and any medical testimony. The appeal may be given to a qualified member(s) of
Senior Staff for review if the individual(s) hearing the appeal is unable to make a decision.

• Final decisions will be made within the stated timeframes. You will be notified of the appeal outcome within two (2) business days of the decision. Notices of denials will include the medical basis for the decision and any further appeal rights you may have.

Expedited appeals for issues other than medical necessity

Preferred Care has an expedited process to handle appeals as quickly as possible. This process is used when a delay would put your health in danger.

• The appeal is resolved within 48 hours after it was received.
• You will be notified of the outcome. The notice will include a reason for the decision and explain any further appeal rights.
• All notices of denials will include the medical basis for the decision and any further appeal rights you may have.

You or your representative will be notified of the outcome within 24 hours by phone. A written notice is also sent within 24 hours.

Further Appeal Rights

If you disagree with your appeal outcome, you will be told that you may direct a further appeal to either:

State of New York
Department of Health
Corning Tower
Governor Nelson A. Rockefeller Empire State Plaza
Albany, New York 12237
(800) 206-8125
www.health.state.ny.us

State of New York Insurance Department
1 Commerce Plaza
Albany, New York 12257
(800) 342-3736
www.ins.state.ny.us

You have the right to contact the Department of Health at any time during the complaint process. If you have any questions about these procedures or if we can help, Contact Member Services.

B. Appeal due to adverse determination based on medical necessity or experimental/investigational treatment

• Preferred Care must receive your appeal within 180 calendar days from the date of the original denial notice. You can get a copy of the appeal form from Member Services. Preferred Care will start processing the appeal right away if it is received verbally. A copy of the form will be sent to you to review, change if necessary, sign and return to Preferred Care. A medical reviewer will be available within one (1) business day of the notice of appeal. You will be notified that the appeal has been received within five (5) business days after it is received. The notice will include the name, address and telephone number of the person who will respond to your appeal. It also will tell you if additional information is necessary to process your appeal. Your appeal will be documented and thoroughly investigated.
• A summary of the appeal is sent to a clinical peer reviewer chosen by the Medical Director. The reviewer is a licensed provider in the same or similar specialty as the health care provider who manages the medical condition under review. The reviewer is not the same person or a subordinate of the person who made the initial decision.
• A decision and notification will take place within 30 calendar days of receiving your appeal. You will receive a notice of the decision and the medical basis for the decision from the clinical peer reviewer within two (2) business days of the decision.

If the clinical peer reviewer upholds the denial, consider this your final adverse determination. Member Services will send you information on your right to an external appeal. If we fail to make an appeal decision within the stated timeframe, consider this as a reversal of our initial decision. The services in question will be approved.

Expedited appeal due to an adverse determination regarding medical necessity or experimental/investigational treatment

Preferred Care has an expedited process to handle appeals as quickly as possible. This process is used in specific cases of adverse determination. These cases involve continued or extended health care services, procedures, treatments, or additional services for a member undergoing a course of ongoing treatment prescribed by a health care provider. This process is also used when the health care provider believes an appeal is needed right away.

• Preferred Care will begin processing the dispute right away if it is received verbally. A copy will be sent to you to review, change if necessary and sign.
  Your provider will be notified if additional information is needed. Access to a clinical peer reviewer is available within one (1) business day of notice of appeal.
• A decision is made within 48 hours after your appeal was received.
• You are notified of the reviewer’s decision within 24 hours. Any denial of claims based on clinical reasons will be made by a peer reviewer. This reviewer is different from the person who made the initial decision and is not a subordinate of the person who made the initial decision. All notices of denials will include the medical basis for the decision and any further appeal rights you may have. The notice will include the name, address and telephone number of a person you may contact.
• If we fail to make a decision within the stated timeframe, consider this a reversal of the initial decision. The services in question will be approved. If the expedited appeal does not result in a decision that is satisfactory to you, you may further appeal through the Standard Appeal Process or the External Appeal Process.

External appeal process following a denial based on medical necessity or experimental/investigational treatment.

You may ask for an external appeal from New York State if:

• you have received a final adverse determination based on medical necessity
  for services covered under your benefit package; or
• you have been denied an experimental or investigational treatment from
  Preferred Care.

You need to have a final adverse determination from the first level appeal offered (Clinical Peer Review), unless both you and Preferred Care have jointlyagreed to waive the internal appeal process.

• An external appeal application form will be mailed to you with your final adverse determination. You also may get an External Appeal application from:

– NYS Department of Insurance Web site at www.ins.state.ny.us or call (800) 400-8882;
– NYS Department of Health Web site at www.health.state.ny.us; or
– Preferred Care Member Services.

The application will include clear instructions on how to fill out the form.

• You need to ask for an external appeal within 45 days after you receive your final adverse determination from Preferred Care or within 45 days of when you and Preferred Care agree to waive the internal appeal process.
• You may lose your right to an external appeal if you do not file an application within 45 days after you receive your final adverse determination from the initial internal plan appeal. The request is made by completing the application and sending it to the New York State Insurance Department at the address listed below:

New York State Insurance Department
1 Commerce Plaza
Albany, NY 12257
(800) 342-3736
www.ins.state.ny.us

You and your health care provider will need to submit all necessary medical information related to your condition and request for services.

You may request an expedited review if your provider believes that a delay in providing the recommended treatment may cause a serious threat to your health. The external appeal agent will make a decision within three (3) days for expedited appeals. The agent will make every effort to notify you and Preferred Care of the decision right away. A written notice from the external appeal agent will follow as soon as possible.

• An external appeal agent will make a decision on a standard appeal within 30 calendar days of receiving the request from the state. Five (5) additional days may be added if more information is needed.
• If the agent decides the information provided is different from what was reviewed by the plan, the plan will have three (3) additional days to reconsider or uphold its decision. You and Preferred Care will be notified within two (2) business days of the decision being made.

To file an external appeal, send your application and a $50.00 fee (made payable to Preferred Care) to the New York State Insurance Department. This fee will be refunded to you if the external appeal is decided in your favor. You may apply to Preferred Care for a fee waiver if this fee would cause a financial hardship to you. There are no other fees for an external appeal.

An external appeal agent licensed by the state will review your request to determine if the denied service is medically necessary and should be provided and/or paid for by Preferred Care. Expert clinical peer reviewers handle all reviews. The results are final and binding.

To reach Preferred Care Member Services

• Visit the Contact Member Services Web page for information about contacting Member Services by phone or e-mail.
• Or write to us at: Preferred Care, Member Services, 220 Alexander St., Rochester, NY 14607.

Last updated: August 7, 2006