(Section 10)
Filing a grievance with UPREHS
What types of problems might lead you to filing a grievance?
UPREHS Medicare Secondary Plan grievances
To file a grievance with the UPREHS MSP
For quality of care problems, you may also complain to the QIO
Who may file a grievance?
Fast grievances
(Section 11)
Complaints and Appeals About your HCPP Medical Services and Benefits
How to make complaints in different situations
To file a UPREHS Medicare Secondary Plan payment appeal

Part 1: Requests for Payment or Medical Care that Would Normally Be Processed or Paid through the UPREHS HCPP
Initial determinations
WHO MAY ASK FOR AN INITIAL DETERMINATION?
ASKING FOR A FAST DETERMINATION
WHAT HAPPENS IF WE DECIDE AGAINST YOU?

Appeal Level 1: Appeal to UPREHS HCPP for our Denial of a Part B Medical Service or Payment that we Normally Process/Pay
WHO MAY FILE YOUR APPEAL OF THE INITIAL DETERMINATION?
HOW SOON MUST YOU FILE YOUR APPEAL?
HOW TO FILE YOUR APPEAL
GETTING INFORMATION TO SUPPORT YOUR APPEAL
HOW SOON MUST WE DECIDE ON YOUR APPEAL?

Appeal Level 2: Independent Review Entity (IRE)
HOW TO FILE YOUR APPEAL
HOW SOON MUST THE IRE DECIDE?
IF THE IRE DECIDES COMPLETELY IN YOUR FAVOR

Appeal Level 3: Administrative Law Judge (ALJ)
HOW TO FILE YOUR APPEAL
HOW SOON WILL THE JUDGE MAKE A DECISION?
IF THE JUDGE DECIDES IN YOUR FAVOR

Appeal Level 4: Medicare Appeals Council (MAC)
HOW TO FILE YOUR APPEAL
HOW SOON WILL THE COUNCIL MAKE A DECISION?
IF THE COUNCIL DECIDES IN YOUR FAVOR:

Appeal Level 5: Federal Court
HOW SOON WILL THE JUDGE MAKE A DECISION?
IF THE JUDGE DECIDES IN YOUR FAVOR
IF THE JUDGE RULES AGAINST YOU
FAVORABLE DECISIONS BY THE ALJ, MAC, OR A FEDERAL COURT JUDGE

PART 2. Complaints (appeals) if you think you are being discharged from the hospital too soon
INFORMATION YOU SHOULD RECEIVE DURING YOUR HOSPITAL STAY
REVIEW OF YOUR HOSPITAL DISCHARGE BY THE QUALITY IMPROVEMENT ORGANIZATION
WHAT IS THE “QUALITY IMPROVEMENT ORGANIZATION”?
GETTING A QIO REVIEW OF YOUR HOSPITAL DISCHARGE
WHAT HAPPENS IF THE QIO DECIDES IN YOUR FAVOR?
WHAT HAPPENS IF THE QIO DENIES YOUR REQUEST?
WHAT IF YOU DO NOT ASK THE QIO FOR A REVIEW BY THE DEADLINE?

PART 3. Complaints (appeals) if you think your coverage for SNF, home health or comprehensive outpatient rehabilitation facility services is ending too soon
INFORMATION YOU WILL RECEIVE DURING YOUR SNF, HHA OR CORF STAY
HOW TO GET A REVIEW OF YOUR COVERAGE BY THE QUALITY IMPROVEMENT ORGANIZATION
HOW SOON DO YOU HAVE TO ASK THE QIO TO REVIEW YOUR COVERAGE?
WHAT WILL HAPPEN DURING THE REVIEW?
WHAT HAPPENS IF THE QIO DENIES YOUR REQUEST?
WHAT IF YOU DO NOT ASK THE QIO FOR A REVIEW BY THE DEADLINE?

Grievance, Exceptions & Appeals Forms


Filing a grievance with UPREHS
The terms we, us, and UPREHS are used throughout Sections 10 and 11, but the grievance or appeal may not be the type that UPREHS would make as an HCPP. Carefully examine your case, the benefits and the type of request. It will delay your process if you send a decision request to UPREHS that should go to Railroad Medicare, Original Medicare, or a Medicare Intermediary on facility services.

A grievance is different from a request for an organization determination, (a request for a coverage determination), or a request for an appeal as described in Section 11of this manual because grievances do not involve problems related to coverage or payment for care (or your prescription benefits under Medicare Part D), problems about being discharged from the hospital too soon, and problems about coverage for Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending to soon.

For problems about coverage or payment for care, problems about being discharged from the hospital too soon, and problems about coverage for SNF, HHA, or CORF services ending too soon, you must follow the rules outlined in Section 11.

We encourage you to let us know right away if you have a complaint. Call UPREHS Customer Services at 1-800-547-0421. UPREHS will try to resolve any complaint you have over the phone. If the service is not one that UPREHS would handle, we will direct you to the correct entity. If you request a written response we will respond in writing to you. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from the UPREHS Medicare Plans or penalized in any way if you make a complaint.

As stated in Section 2, you may use nonparticipating providers. However if you use nonparticipating providers for care that is not an emergency or urgently needed care, UPREHS MSP benefit payments are reduced to 40%. If you have a complaint about care from a nonparticipating provider, your grievance must be filed with Original Medicare.

If you have a dispute regarding a service provided by a hospital or skilled nursing facility, or any facility, you will follow Original Medicare rules as provided in your 2009 Medicare & You book. Please refer to your 2009 Medicare & You book for additional guidance on your appeal rights under Original Medicare. If you do not have a 2009 Medicare & You book, please call 1-800-MEDICARE (1-800-633-4227) and they will assist you in obtaining this guidance.

For disputes involving prescription drugs covered under Medicare Part D, please follow the instructions in your UPREHS Prime Medicare Plan 2009 Benefit Guide.

• Problems with the quality of the medical care you receive, including quality of care during a hospital stay.
• If you feel that you are being encouraged to leave (disenroll from) UPREHS.
• Problems with the UPREHS Customer Service you receive.
• Problems with how long you have to wait on the phone, in the waiting room, or in the exam room.
• Problems with getting appointments when you need them, or waiting too long for them.
• Rude behavior by doctors, nurses, receptionists, or other staff.
• Cleanliness or condition of doctor’s offices, clinics, or hospitals.

• If you disagree with our decision not to give you a fast decision or a fast appeal.
• You believe our notices and other written materials are hard to understand.
• We don’t give you a decision within the required timeframe.
• We don’t give you required notices.

If you have one of these types of problems and want to make a complaint, it is called filing a grievance. In certain cases, you have the right to ask for a fast grievance, meaning your grievance will be decided within 24 hours. We discuss these fast grievances in more detail in Section 11.

• You may file a written grievance to UPREHS stating exactly who, where, what and when the problem occurred. It is not possible to respond to a grievance if we are not supplied with sufficient facts and information to allow our staff to investigate.

• UPREHS will acknowledge receipt of your grievance within 30 days, and very often the matter can be resolved within that time. UPREHS may need more time for a resolution if it is a very complicated matter. In that case UPREHS will return a written determination regarding the grievance within 60 days of receipt of your written filing.

Mail your UPREHS grievance to:
UPREHS
PO Box 161020
Salt Lake City, UT 84116-1020

• UPREHS HCPP can only perform your Medicare appeal if we processed the original Part B claim from a UPREHS participating provider.

• All of your appeals for Medicare Part B claims that were originally processed by Railroad Medicare (Palmetto GBA) must go directly to them and not UPREHS. For more information on how to file an Original Medicare appeal, please refer to your 2009 Medicare & You book.

• All of your appeals for Medicare Part A benefits are made to the Original Medicare intermediary that processed your claim. The UPREHS HCPP does not process your Medicare Part A services. However, the UPREHS MSP does pay secondary to Medicare for your Part A benefits.

UPREHS participating physicians can send your claims to either UPREHS HCPP or Railroad Medicare (Palmetto GBA) because you are still using your Original Medicare benefits. If a UPREHS participating physician sends your claims to Railroad Medicare, we cannot perform a Medicare appeal for you. Your appeal must go to Railroad Medicare.

Railroad Medicare must pay all of your Medicare Part B claims for services from out-of-network providers that do not participate with UPREHS. As a UPREHS Medicare member, you may choose to get care from nonparticipating providers anywhere, and at any time using your Original Medicare benefits. Your UPREHS MSP benefit payment is reduced to 40% for out-of-network services except for emergency or urgent care for the first 24 hours.

When UPREHS participating physicians send your claims to Railroad Medicare (Palmetto GBA), we cannot automatically pay your UPREHS Medicare Secondary Plan benefits; either you or the physician must send the Medicare Summary Notice (MSN) and a copy of the claim to UPREHS to receive your MSP payment.

• You, your representative or a participating provider must file your appeal in writing within 60 days of the time the claim for Medicare secondary payment was processed by UPREHS MSP. Additional information that may aid in reconsidering the payment must be submitted at the time of your appeal. UPREHS must return a written determination to you within 30 days from the date of receipt of your written appeal.

• Should we uphold our initial payment decision and you do not agree, you can next appeal to the President of UPREHS within 60 days of that decision. The President has 60 days in which to make a decision on this appeal.

• If the President upholds the initial payment decision and you still do not agree, you may make a final appeal to the UPREHS Board of Trustees. Instructions on how to appeal to the Board of Trustees will be supplied in to you in the President’s response.

UPREHS
PO Box 161020
Salt Lake City, UT 84116-1020

This section tells you how to complain about services or payment in each of the following situations:

• Part 1. Requests Medicare Part B payments or medical care that would normally be processed/paid through the UPREHS HCPP.

• Part 2. Complaints if you think you are being asked to leave the hospital too soon.

• Part 3. Complaints if you think your coverage for skilled nursing facility (SNF), home health (HHA) or comprehensive outpatient rehabilitation facility (CORF) services is ending too soon.

If you want to make a complaint about any type of problem other than those that are listed above, a grievance is the type of complaint you would make. For more information about grievances, including how to file a grievance, see Section 10.

This part explains what you can do if you have problems getting the Part B medical care or service you request, or payment (including the amount you paid) for a Part B medical care or service you already received that would normally be processed/paid through the UPREHS HCPP. If you have problems getting the Part B medical care or services you need, or payment for a Part B service you already received, you must request an initial determination with UPREHS.

Intial Determinations
The initial determination is the starting point for dealing with requests you may have about covering a Part B medical care or service that you need, or paying for a Part B medical service that you already received. Initial determinations are called organization determinations. With this decision we tell you whether we will provide the Part B medical care or service you are requesting through the UPREHS HCPP or pay for the Part B medical care or service you already received.

When an initial decision is made, it is the interpretation of how the benefits and services that are covered by Original Medicare apply to your specific situation. This Benefit Guide and your 2009 Medicare & You book, describe the benefits and services covered by Original Medicare and UPREHS MSP, including any limitations that may apply to these services. This booklet also lists exclusions (services that are not covered by Original Medicare and/or UPREHS MSP).

The following are examples of requests for initial determinations:

• If you are told that Medicare does not cover the medical treatment your doctor or other medical provider wants to give, and you believe that Medicare covers this treatment.
• If you are being told that a treatment or service you have been getting will be reduced or stopped, and you believe that this could harm your health.
• If you have received care that you believe Medicare should cover, but we have refused to pay for this care because we say it is not covered.

• If any doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will give you a fast decision.
  
  
• If you ask for a fast decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast initial decision, we will send you a letter informing you that if you get a doctor’s support for a fast decision, we will automatically give you a fast decision. The letter will also tell you how to file a grievance if you disagree with our decision to deny your request for a fast review. It will also tell you about your right to ask for a fast grievance. If we deny your request for a fast initial decision, we will give you a standard decision.

Appeal Level 1: Appeal to UPREHS HCPP for our Denial of a Part B Medical Service or Payment that we Normally Process/Pay

You may ask us to review our initial determination, even if only part of that decision is not what your requested. An appeal to UPREHS HCPP about Part B medical care or services is also called reconsideration. Please call us at 1-800-547-0421if you need help in filing your appeal. If the decision is not one that would be made by UPREHS, we will direct you to the proper resource or you can call Medicare at 1-800-633-4227.

Who may file your appeal of the initial determination?
If you are appealing an initial determination about Part B medical care or services that UPREHS HCPP would normally process/pay, the rules about who may file an appeal are the same as the rules about who may ask for an organization determination. Follow the instructions under Who may ask for an initial determination. If the decision is not one that would be made by UPREHS, we will direct you to the proper resource or you can call Medicare at 1-800-633-4227.

How soon must you file your appeal?
You must file your appeal within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline. If the decision is not one that would be made by UPREHS HCPP, we will direct you to the proper resource or you can call Medicare at 1-800-633-4227.

• Asking for a standard appeal
  • To ask for a standard appeal about a Part B medical care or service that has been processed/paid by the UPREHS HCPP, a signed, written appeal request must be sent to UPREHS at: UPREHS Appeals, PO Box 161020, Salt Lake City, UT 84116. Or you may call Customer Services at 1-800-547-0421 Monday through Friday from 7:30 AM to 4:30 PM, Mountain Time.

• Asking for a fast appeal
• If you are appealing a decision we made about giving you a Part B UPREHS HCPP medical care or service that you have not received yet, you and/or your doctor will need to decide if you need a fast appeal. The rules about asking for a fast appeal are the same as the rules about asking for a fast initial determination. You, your doctor, or your representative may ask us for a fast appeal by calling, faxing, or writing us at the numbers or address listed on the cover of this book.
  
Be sure to ask for a "fast" or "expedited" review. Remember, if your doctor provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically give you a fast appeal. If you ask for a fast decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a “fast grievance.” You have the right to file a fast grievance if you disagree with our decision to deny your request for a fast review (for more information about fast grievances, see Section 10). If we deny your request for a fast appeal, we will give you a standard appeal.

• In writing, to UPREHS, PO Box 161020, Salt Lake City, UT 84116-1020.
• By fax, at 801-595-4399
• By telephone — if it is a fast appeal — at 1-800-547-0421.
• In person, at UPREHS, 1040 North 2200 West Suite 200, Salt Lake City, Utah 84116.

• For a decision about UPREHS HCPP payment for care or services you already received.
• After your appeal is received, a decision must be made within 60 days. If the decision is not made within 60 days, your appeal automatically goes to Appeal Level 2.

• For a standard decision about UPREHS HCPP medical care or services you have not received.
• Remember, this must be Part B medical care or services you want to receive from a UPREHS HCPP participating physician and one that UPREHS HCPP would normally process/pay. If the decision is not one that would be made by UPREHS, we will direct you to the proper resource or you can call Medicare at 1-800-633-4227. After we receive your appeal, we have up to 30 days to decide, but will make it sooner if your health condition requires. However, if you request it, or if we find that some information is missing which can help you, we can take up to 14 more days to make our decision. If we do not tell you our decision within 30 days (or by the end of the extended time period), your request will automatically go to Appeal Level 2.

• For a fast decision about Part B medical care or services you have not received that UPREHS HCPP would normally process/pay.
• Remember, this must be medical care you want to receive from a UPREHS participating physician. If the decision is not one that would be made by UPREHS, we will direct you to the proper resource or you can call Medicare at 1-800-633-4227. After we receive your appeal, we have up to 72 hours to make a decision, but will make it sooner if your health requires. However, if you request it, or if there is some information is missing which can help you, we can take up to 14 more days to make our decision. If we do not tell you our decision within 72 hours (or by the end of the extended time period), your request will automatically go Appeal Level 2.
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• For a decision about payment for Part B UPREHS HCPP medical care or services you already received.
• We must pay within 60 days of the day we received your appeal request. If the decision is not one that would be made by UPREHS, we will direct you to the proper resource or you can call Medicare at 1-800-633-4227.

• For a standard decision about Part B UPREHS HCPP medical care or services you have not received.
• We must authorize or provide you with the care you have asked for as no later than 30 days after we received your appeal request. If we extend the time needed to decide your appeal, we will authorize or provide your medical care when we make our decision. If the decision is not one that would be made by UPREHS HCPP, we will direct you to the proper resource or you can call Medicare at 1-800-633-4227.

• For a fast decision about Part B UPREHS HCPP medical care or services you have not received.
• We must authorize or provide the requested care within 72 hours of receiving your appeal request. If we extended the time needed to decide your appeal, we will authorize or provide your care at the time we make our decision. If the decision is not one that would be made by UPREHS, we will direct you to the proper resource or you can call Medicare at 1-800-633-4227.

Appeal Level 2: Independent Review Entity (IRE)
At the second level of appeal, an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program, reviews it. The IRE has no connection to UPREHS HCPP. You have the right to ask us for a copy of your case file that we sent to this entity.

How to file your appeal
If you asked for Part B UPREHS HCPP medical care or services, or payment for Part B UPREHS HCPP medical care or services, and we did not rule completely in your favor at Appeal Level 1, your appeal is automatically sent to the IRE.

How soon must the IRE decide?
The IRE has the same amount of time to make its decision as UPREHS had at Appeal Level 1.

If the IRE decides completely in your favor
The IRE will tell you in writing about its decision and the reasons for it.

• For a decision about payment for Part B UPREHS HCPP medical care or services you already received.
• We must pay within 30 days after we receive notice reversing our decision.

• For a standard decision about Part B UPREHS HCPP medical care or services you have not yet received.
• We must authorize your requested Part B UPREHS HCPP medical care or service within 72 hours, or provide it to you within 14 days after we receive notice reversing our decision.

• For a fast decision about Part B UPREHS HCPP medical care or services.
• We must authorize or provide your requested Part C medical care or services within 72 hours after we receive notice reversing our decision.
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• The decision is not completely favorable to you, or
• The decision tells you that the MAC decided not to review your appeal request.

• Your right to get all medically necessary hospital services covered.
• Your right to know about any decisions that the hospital, your doctor, or anyone else makes about your hospital stay and who will pay for it.
• That your doctor or the hospital may arrange for services you will need after you leave the hospital.
• Your right to appeal a discharge decision.

• Why you are being discharged.
• The date that Original Medicare will stop covering your hospital stay (stop paying their share of your hospital costs).
• What you can do if you think you are being discharged too soon.
• Who to contact for help.

• You must ask the QIO for a fast review of whether you are ready to leave the hospital. This fast review is also called an immediate review.
  
  
• You must be sure that you have made your request to the QIO no later than noon on the first working day after you are given written notice that you are being discharged from the hospital. This deadline is very important. If you meet this deadline, you are allowed to stay in the hospital past your discharge date without paying for it yourself, while you wait to get the decision from the QIO (see below).

• If you ask Original Medicare for a fast appeal of your discharge and you stay in the hospital past your discharge date, you run the risk of having to pay for the hospital care you receive past your discharge date. Whether you have to pay or not depends on the decision Original Medicare makes.
• If Medicare decides, based on the fast appeal, that you need to stay in the hospital, they will continue to cover your hospital care for as long as medically necessary.
• If Medicare decides that you should not have stayed in the hospital beyond your discharge date, they will not cover any hospital care you received after the discharge date unless the independent review organization overturns their decision.
• If Original Medicare denies a continued hospital stay, your UPREHS MSP will not pay for any portion of the continued stay.

• If Original Medicare decides, based on the fast appeal, that you need to continue to get your services covered, then they will continue to cover your care for as long as medically necessary.
• If Original Medicare decides that you should not have continued getting coverage for your care, they will not cover any care you received after the termination date.
• Remember, if Original Medicare decides not to continue coverage, then your UPREHS MSP will not make payment either.