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Member Appeals and Grievance Process

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Overview

Members are encouraged to let Saint Alphonsus Health Plan know if they have concerns or experience any problems with the Plan or its network providers. Saint Alphonsus Health Plan has representatives available to help members with their questions and concerns.

The procedures described in this section may be used if a member has an appeal or grievance he/ she wants to submit to Saint Alphonsus Health Plan for review and resolution. These procedures include:

  • General information on Medicare appeals procedures.
  • Medicare standard organization determinations and appeals procedures.
  • Medicare expedited / 72-hour organization determinations and appeals procedure.
  • Saint Alphonsus Health Plan grievance procedure.
  • QIO immediate review of hospital discharges.
  • QIO quality of care complaint procedure.

General Information on Medicare Appeals Procedures

Our members have the right to appeal any decision about payment for, or failure to arrange or continue to arrange for, what the member believes are covered services (including non-Medicare covered benefits) under Saint Alphonsus Health Plan. Coverage decisions that are commonly appealed include decisions with respect to:

  • Payment for emergency services, post-stabilization care, or urgently needed services.
  • Payment for any other health services furnished by an out-of-network provider or facility that the member believes should have been arranged for, furnished, or reimbursed by Saint Alphonsus Health Plan.
  • Services not received, but which the member feels Saint Alphonsus Health Plan is responsible to pay for or arrange.
  • Discontinuation of services that the member believes are medically necessary covered services.

Members should use the Saint Alphonsus Health Plan grievance procedure (discussed in this section) for complaints that do not involve coverage decisions such as those set forth. For questions about what type of complaint process to use, members should call Saint Alphonsus Health Plan’s Member Service department toll-free at 1-800-240-3851 (TTY 711).

Members are entitled to a report from Saint Alphonsus Health Plan that describes the number of quality of care grievances and appeals and their dispositions processed during the most recent calendar year. Members may contact the Member Services Department for a copy of this report.

As discussed in this section, Saint Alphonsus Health Plan has a standard determination and appeals procedure and an expedited determination and appeals procedure.

Who May File an Appeal

  • A member may file an appeal.
  • A member’s legally authorized representative such as a durable power of attorney or legal guardian may file the appeal for the member on his/her behalf. The member may also appoint an individual to act as his/her representative to file the appeal by following the steps below:
    • Complete and submit form CMS -1696, appointment of representative form.
    • The appellant must include this signed statement with the appeal.
  • An out-of-network provider who has furnished a service to a member may file a standard appeal of a denied claim if he/she completes a waiver of payment statement indicating he/she will not bill the member regardless of the outcome of the appeal.

Support for the Appeal

Saint Alphonsus Health Plan is responsible for gathering all necessary medical information relevant to the request for reconsideration (appeal). However, it may be helpful to include additional information to clarify or support the request. For example, a member may want to include in the appeal request information such as medical records or provider opinions in support of the request. To obtain medical records, the member may send a written request to his/her primary care provider. If medical records from a specialist are not included in the medical record from the primary care provider, the member may need to make a separate request to the specialist who provided medical services. It is the member’s responsibility to pay any fee charged by the health care provider for medical records.

The member has the opportunity to provide additional information in person or in writing. In the case of an expedited decision or appeal, the member or the member’s authorized representative may submit evidence in person, via telephone, or in writing transmitted by fax to the address and telephone number referenced under the expedited/72-hour review procedure.

Assistance with Appeals

In some situations a member may want help or guidance from someone who is not connected with Saint Alphonsus Health Plan. The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state.

 

Idaho Senior Health Insurance Benefits Advisors (SHIBA)

Phone: 800-257-4422 
Web: https://doi.idaho.gov/shiba/

Medicare Standard Organization Determination and Appeals Procedures

If a member specifically requests a particular service from a health care provider, or if that health care provider specifically requests authorization for a service from Saint Alphonsus Health Plan, it is considered a request for an organization determination on the service.

If the request is made in writing to Saint Alphonsus Health Plan (at the address listed below) to make payment for a service a member has already received, this a request for a Saint Alphonsus Health Plan determination on the payment.

In the case of a standard determination, Saint Alphonsus Health Plan must make a determination (decision) on the request for payment or provision of services within the following time frames:

  • Request for Service. If a member requests services, or requires prior authorization of a referral for services, Saint Alphonsus Health Plan must make a decision as expeditiously as the member’s health requires, but no later than fourteen (14)  calendar days after receiving the request for service. An extension of up to fourteen (14) calendar days is permitted if the member requests the extension or if Saint Alphonsus Health Plan has a need for additional information and the extension of time benefits the member. An example of this would be if Saint Alphonsus Health Plan would need additional medical records from out-of-network providers that could change a denial decision.
  • Request for Payment. If a member requests payment for services already received, Saint Alphonsus Health Plan will usually make a decision on whether or not to pay the claim no later than thirty (30) calendar days from receiving the request, but in no case will this period exceed sixty (60) days.

Saint Alphonsus Health Plan must notify the member in writing of any adverse decision (partial or complete) within the time frames listed above. The notice must state the reasons for the denial and also must inform the member of his/her right to file an appeal. If the member has not received such a notice within fourteen (14) calendar days of the request for services, or within sixty (60) days of a request for payment, the member may assume the decision is a denial and may file an appeal.

To proceed with the Medicare Standard Appeals Procedure, the following steps will occur:

  1. The member must submit a written request to Saint Alphonsus Health Plan, Attention: Appeals and Grievance Coordinator, 3100 Easton Square Place, Third Floor – Health Plan Columbus, Ohio 43219. The written request must be submitted within sixty (60) calendar days of the date of the notice of the initial decision.
  2. Saint Alphonsus Health Plan will conduct a reconsideration and notify the member in writing of the decision, using the following time frames:
    • Request for Service. If the appeal is for a denied service, Saint Alphonsus Health Plan must notify the member of the reconsideration decision as expeditiously as the member’s health requires, but no later than thirty (30) days from receipt of the request. The time frame may be extended by up to fourteen (14) days if the member requests the extension or if Saint Alphonsus Health Plan needs additional information, and the extension of time benefits the member, for example, if additional medical records are needed from out-of-network providers that could change a denial decision. Again, Saint Alphonsus Health Plan must make a decision as expeditiously as the member’s health requires, but no later than the end of any extension period.
    • Request for Payment. If the appeal is for a denied claim, Saint Alphonsus Health Plan must notify the member of the reconsideration determination no later than sixty (60) days after receiving the request for a reconsideration determination.
  3. The reconsideration decision will be made by a person or persons not involved in the initial decision. All reconsiderations of adverse organization determinations based on ‘lack of medical necessity’ must be made by a provider with appropriate expertise in the field of medicine appropriate for the services at issue. The member or the member’s authorized representative may present or submit relevant facts and/or additional evidence for review either in person or in writing to Saint Alphonsus Health Plan.
  4. If Saint Alphonsus Health Plan decides fully in the member’s favor on a request for a service, Saint Alphonsus Health Plan must provide or authorize the requested service within thirty (30) days of the date the request for reconsideration was received. If Saint Alphonsus Health Plan decides fully in the member’s favor on a request for payment, Saint Alphonsus Health Plan must make the requested payment within sixty (60) days of the date the request for reconsideration was received.
  5. If Saint Alphonsus Health Plan decides to uphold the original adverse decision, either in whole or in part, Saint Alphonsus Health Plan will automatically forward the entire file to MAXIMUS for a new and impartial review. MAXIMUS is CMS’ independent contractor for appeal reviews involving Medicare Advantage managed care plans such as Saint Alphonsus Health Plan. Saint Alphonsus Health Plan must send MAXIMUS the file within 30 days of a request for services and within 60 days of a request for payment. MAXIMUS will either uphold Saint Alphonsus Health Plan’s decision or issue a new decision. If Saint Alphonsus Health Plan forwards the case to MAXIMUS, Saint Alphonsus Health Plan will notify the member of the decision as discussed above.
  6. For cases submitted for review, MAXIMUS will make a reconsideration decision and notify the member in writing of their decision and the reasons for the decision. If MAXIMUS upholds the Plan’s decision, their notice will inform the member of rights to a hearing before an administrative law judge of the Social Security Administration (SSA) (see below for further levels of appeal). If MAXIMUS (or a higher appeal level) decides in favor of the member, Saint Alphonsus Health Plan must pay for, provide or authorize the service as expeditiously as the member’s health condition requires, but no later than 60 days from the date notice reversing the Plan’s decision is received.

If MAXIMUS does not rule fully in the member’s favor, there are further levels of appeal:

  1. If there is at least $180 (2024 amount) in controversy, the member may request a hearing before an administrative law judge (ALJ) by submitting a written request to Saint Alphonsus Health Plan, MAXIMUS or the SSA within sixty (60) days of the date of MAXIMUS’ notice that the reconsideration decision was not in the member’s favor. This sixty (60) day notice may be extended for good cause. All hearing requests will be forwarded to MAXIMUS. MAXIMUS will then forward the request and the reconsideration file to the hearing office. Saint Alphonsus Health Plan will also be made a party to the appeal at the ALJ level.
  2. Either the member or Saint Alphonsus Health Plan may request a review of an ALJ decision by the Medicare Appeals Council, which may either review the decision or decline review.
  3. If the amount involved is $1,840 (2024 amount) or more, either the member or Saint Alphonsus Health Plan may request that a decision made by the Medicare Appeals Council, or the ALJ if the Medicare Appeals Council has declined review, be reviewed by a federal district court.
  4. Any initial or reconsidered decision made by Saint Alphonsus Health Plan, MAXIMUS, the ALJ, or the Medicare Appeals Council can be reopened by any party (a) within twelve months, (b) within four (4) years for just cause, or (c) at any time for clerical correction of an error or in cases of fraud.
  5. The reconsidered determination is final and binding upon Saint Alphonsus Health Plan. If there is a binding arbitration clause in the member’s contract or individual election form, it does not apply to disputes subject to CMS’ appeals process.

Medicare Expedited/72-Hour Determination and Appeal Procedure

Members have the right to request and receive expedited decisions affecting medical treatment in ‘time- sensitive’ situations. A ‘time-sensitive’ situation is one in which waiting for a decision to be made within the time frame of the standard decision-making process could seriously jeopardize the member’s life, health or ability to regain maximum function.

If Saint Alphonsus Health Plan decides, based on medical criteria, that a situation is ‘time-sensitive’ or if any provider makes the request for the member by calling or writing in support of the request for an expedited review, Saint Alphonsus Health Plan will issue a decision as expeditiously as the member’s health requires, but no later than seventy-two (72) hours after receiving the request. This time frame may be extended by up to fourteen (14) days if the member requests the extension or if the Plan needs additional information and the extension of time benefits the member; for example, if Saint Alphonsus Health Plan needs additional medical records from out-of-network providers that could change a denial decision. Again, Saint Alphonsus Health Plan must make a decision as expeditiously as the member’s health requires, but no later than the end of any extension period.

Types of Decisions Subject to Expedited/72­-Hour Review

  • Expedited Determinations. If a member believes he/she needs a service, or continues to need a service, and believes it is a ‘time-sensitive’ situation, the member or any provider (including a provider with no connection to Saint Alphonsus Health Plan) may request that the decision be expedited. If Saint Alphonsus Health Plan decides that it is a ‘time-sensitive’ situation, or if any provider states that it is one, Saint Alphonsus Health Plan will make a decision on the request for a service on an expedited/72-hour basis (subject to an extension as discussed above).
  • Expedited Appeals. If a member wants to request a reconsideration (appeal) of a decision by Saint Alphonsus Health Plan to deny a service requested or to discontinue a service the member is receiving that he/she believes is a medically necessary covered service and the member believes it is a ‘time-sensitive’ situation, the member may request that the reconsideration (appeal be expedited. If a provider wishes to file an expedited appeal for the member, the member must give him or her authorization to act on the member’s behalf. If Saint Alphonsus Health Plan decides that it is a ‘time-sensitive’ situation, or if any provider states that it is one, Saint Alphonsus Health Plan will make a decision on the appeal on an expedited/72-hour basis. This time frame may be extended by up to fourteen (14) days if the member requests the extension or if Saint Alphonsus Health Plan needs additional information, and the extension of time benefits the member; for example, if Saint Alphonsus Health Plan needs additional medical records from out-of-network providers that could change a denial decision.

Again, Saint Alphonsus Health Plan must make a decision as expeditiously as the member’s health requires, but no later than the end of any extension period.

Examples of service decisions which members may appeal on an expedited basis, when believed to be a ‘time-sensitive’ situation, include the following:

  • Denial of a service requested.
  • Services discontinued too soon, according to the member, for example:
    • Being discharged from a skilled nursing facility too soon and missing the deadline for a QIO review.
    • Home health care is being discontinued too soon and missing the deadline for a QIO review.

The procedures for requesting and receiving an expedited determination or an expedited appeal (an expedited decision) are described in the following sections.

How to Request an Expedited/72-Hour Review

To request an expedited/72-hour review, a member or the member’s authorized representative may call, write or visit Saint Alphonsus Health Plan. Members must specify an expedited/72-hour review when making the request.

How an Expedited/ 72-Hour Determination/ Review Request Will be Processed

  1. Upon receiving a request for an expedited decision, Saint Alphonsus Health Plan will determine whether the request meets the definition of ‘time-sensitive’:
    • If the request does not meet the definition, it will be handled within the standard review process. The member will be informed by telephone or in person whether the request will be processed through the expedited seventy-two (72) hour review or the standard review process. The member will also be sent a written confirmation within two (2) working days of the telephone call or personal contact. If the member disagrees with Saint Alphonsus Health Plan’s decision to process the request within the standard time frame, the member may file a grievance with Saint Alphonsus Health Plan. The written confirmation letter will include instructions on how to file a grievance. If the request is ‘time-sensitive,’ the member will be notified of Saint Alphonsus Health Plan’s decision as expeditiously as the member’s health requires but no later than seventy-two (72) hours after receipt of the request.
    • An extension up to fourteen (14) calendar days is permitted for a 72-hour request for determination/appeal, if the member asks for the extension or Saint Alphonsus Health Plan needs more information and the extension of time benefits the member; for example, a member may need time to provide additional information, or Saint Alphonsus Health Plan may need to have additional diagnostic testing completed.
  2. The request must be processed within seventy­ two (72) hours if any provider calls or writes in support of the request for an expedited/72-hour review, and the provider indicates that applying the standard review time frame could seriously jeopardize the life or health of a member or the member’s ability to regain maximum function.
    • If an out-of-network provider supports the request, Saint Alphonsus Health Plan will have 72 hours from the time it receives all the necessary medical information from that out-of-network provider it needs to make a decision.
  3. Saint Alphonsus Health Plan will make a decision on the request for determination/appeal and notify the member within 72 hours of receipt of the request. If Saint Alphonsus Health Plan decides to uphold the original adverse decision, either in whole or in part, the entire file will be forwarded by Saint Alphonsus Health Plan to MAXIMUS for review as expeditiously as the member’s health requires, but no later than 24 hours after the decision. MAXIMUS will send the member a letter with their decision within 72 hours of receipt of the case from Saint Alphonsus Health Plan.

There are four possible dispositions to a request for expedited determination/appeal. They are:

  1. The request to expedite the determination/appeal decision is approved, a decision is made in 72 hours and the member is notified that Saint Alphonsus Health Plan will cover or continue the service.
  2. The request to expedite the determination/appeal decision is approved, Saint Alphonsus Health Plan makes a decision in 72 hours and notifies the member that the Plan will not cover or continue the service.
  3. The request to expedite the determination/appeal decision is not approved, and Saint Alphonsus Health Plan tells the member that his/her request will be handled under the standard determination/appeal process.
  4. The request to expedite the determination/appeal decision cannot be made in 72 hours, and Saint Alphonsus Health Plan lets the member know that the Plan will need up to an additional 14 days to process the request.

When requesting an expedited determination/ appeal, if a member does not hear from Saint Alphonsus Health Plan within 72 hours of the request, the member can assume that the request has been denied. Saint Alphonsus Health Plan’s failure to notify the member in a timely manner – within 72 hours – constitutes a denial which may be appealed.

Saint Alphonsus Health Plan Grievance Procedures

Our members have the right to file a complaint— formally called a grievance—about problems observed or experienced, including:

  • Complaints about the quality of services received.
  • Complaints regarding such issues as office waiting times, provider behavior, adequacy of facilities, or other similar member concerns.
  • Involuntary disenrollment situations.
  • Disagreement with Saint Alphonsus Health Plan’s decision to process a request for a service or to continue a service under the standard 14-day time frame rather than the expedited/72-hour time frame.
  • Disagreement with Saint Alphonsus Health Plan’s decision to process an appeal request under the standard 30-day time frame rather than the expedited/72­hour time frame.

Saint Alphonsus Health Plan will attempt to resolve any complaint the member might have. Saint Alphonsus Health Plan will write to the member to let them know how the Plan has addressed the concern within thirty (30) days of receiving the grievance. In some instances, Saint Alphonsus Health Plan will need additional time to address the concern. If additional time is needed, Saint Alphonsus Health Plan will keep the member informed regarding the status of the grievance. Saint Alphonsus Health Plan is required to track all appeals and grievances in order to report cumulative data to CMS and to members, upon request.

Complaints about a decision regarding payment for or provision of, covered services that a member believes are covered by Medicare and should be provided or paid for by Saint Alphonsus Health Plan must be appealed through Saint Alphonsus Health Plan’s Medicare Appeals Procedure (see earlier in this section)

Quality Improvement Organization Immediate Review of Hospital Discharges

Members have the right to receive all the hospital care that is necessary for the proper diagnosis and treatment of illness or injury. According to federal law, discharge date must be determined solely by medical needs. When being discharged from the hospital, members will receive a written notice of explanation called a Notice of Medicare Non-Coverage (NOMNC). This document outlines member rights, and a member does not have to disagree with the non-coverage determination in order to receive it. Hospitals participating with Medicare are required to issue this notice.

Members have the right to request a review by a QIO of any written NOMNC received from Saint Alphonsus Health Plan or from the skilled nursing facility or home health agency on Saint Alphonsus Health Plan’s behalf stating that the Plan will no longer pay for a member’s care. Such a request must be made by noon the day before covered services end. Members cannot be made to pay for the care or a service received before the QIO makes its decision and notifies the member.

If receiving inpatient care from a hospital, members have the right to request a review by a QIO of any written NOMNC from Saint Alphonsus Health Plan or the hospital on Saint Alphonsus Health Plan’s behalf stating that the Plan will no longer pay for a member’s care. Such a request must be made by midnight on the day of discharge. Members cannot be made to pay for the care or services received before the QIO makes it decision and notifies the member, if the notice is timely.

QIOs are groups of physicians who are paid by the federal government to review medical necessity, appropriateness, and quality of hospital treatment furnished to Medicare patients, including those enrolled in a managed care plan (like Saint Alphonsus Health Plan).

 

Idaho QIO: KEPRO. Inc.

KEPRO. Inc. 
5700 Lombardo Center Dr., Ste. 100 
Seven Hills, OH 44131 
Phone: 888-305-6759 
TTY: 855-843-4776 
Web: https://www.keproqio.com/bene/statepages/idaho

Members should review the NOMNC to verify the address and telephone number of the QIO responsible for the facility in which they are a patient.

If a member asks for immediate review by the QIO by noon on the workday following a NOMNC, the member will be entitled to this process instead of the standard appeals process that is described in this section. The member will also be protected from liability for facility services received before the QIO makes its decision. Instead of QIO review, a member may appeal the notice of non-coverage/notice of discharge and medicare appeal rights within 60 days as discussed above by requesting that Saint Alphonsus Health Plan reconsider the decision. The advantage of the QIO review is that members will get the results within three working days if requesting the review on time.Also, members are not financially liable for facility charges incurred during the QIO review process. This same protection does not apply in the case of Saint Alphonsus Health Plan’s reconsideration process.

Members may file an oral or written request for an expedited/72-hour Saint Alphonsus Health Plan appeal only if they have missed the deadline for requesting the QIO review. If a member does not seek QIO review, however, and seeks an expedited reconsideration of the organization determination, the member will be financially responsible for the facility costs incurred from the date the NOMNC is issued if the original determination to discharge is upheld through the appeal process. The member must specifically state that he/she has missed the immediate QIO review deadline, he/she wants an expedited (or 72-hour) Appeal and he/she believes his/her health could be seriously harmed by waiting for a standard appeal.

Members may still request a review by the QIO after the deadline of midnight on the day of discharge for NOMNC appeals. However, the QIO is permitted 2 days to review the case and make a decision if the member is still inpatient but missed the deadline or 30 days if the member has since been discharged. No financial liability protection is extended to the member.

If the member receives an immediate review by the QIO, he/she will not be entitled to a Saint Alphonsus Health Plan expedited reconsideration or standard appeal of the discharge decision.

Quality Improvement Organization Quality of Care Complaint Process

For concerns regarding the quality of care received, a member may also file a complaint with the QIO in his/her state.

This page was last updated 07/31/2024

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