(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
(Section 11)
Information on How to Make a Complaint About Medical Services and Benefits
To file a UPREHS Medicare Secondary Plan payment appeal
How to make complaints in different situations

Part 1: Complaints about what benefit or service UPREHS HCPP, Railroad Medicare, or Original Medicare will provide you or what they will pay for
WHAT ARE COMPLAINTS ABOUT YOUR SERVICES OR PAYMENT FOR YOUR CARE?
WHAT IS AN ORGANIZATION DETERMINATION?
WHO MAY ASK FOR AN INITIAL DECISION ABOUT YOUR MEDICAL CARE OR PAYMENT?
DO YOU HAVE A REQUEST FOR MEDICAL CARE THAT NEEDS TO BE DECIDED MORE QUICKLY THAN A STANDARD TIME FRAME?
ASKING FOR A STANDARD DECISION
ASKING FOR A FAST DECISION
WHAT HAPPENS NEXT WHEN YOU REQUEST AN INITIAL DECISION?

Appeal Level 1: If UPREHS HCPP, or the Original Medicare claims processor denies your request for coverage or payment of a service, you may ask us (or them) to reconsider the decision. This is called an appeal or request for reconsideration.
GETTING INFORMATION TO SUPPORT YOUR APPEAL
HOW DO YOU FILE YOUR APPEAL OF THE INITIAL DECISION?
HOW SOON MUST YOU FILE YOUR APPEAL?
WHAT HAPPENS NEXT IF WE DECIDE COMPLETELY IN YOUR FAVOR?
WHAT HAPPENS NEXT IF WE DENY YOUR APPEAL?

Appeal Level 2: If UPREHS HCPP, or the Original Medicare claims processor denies any part of your Level 1 appeal, your appeal will automatically be reviewed by a government-contracted independent review organization
WHAT INDEPENDENT REVIEW ORGANIZATION DOES THIS REVIEW?
HOW SOON MUST THE INDEPENDENT REVIEW ORGANIZATION DECIDE?
IF THE INDEPENDENT REVIEW ORGANIZATION DECIDES COMPLETELY IN YOUR FAVOR:

Appeal Level 3: If the organization that reviews your case at appeal Level 2 does not rule completely in your favor, you may ask for a review by an Administrative Law Judge
HOW SOON DOES THE JUDGE MAKE A DECISION?
IF THE JUDGE DECIDES IN YOUR FAVOR
IF THE JUDGE RULES AGAINST YOU

Appeal Level 4: Your case may be reviewed by a Medicare Appeals Council
THIS COUNCIL WILL FIRST DECIDE WHETHER TO REVIEW YOUR CASE
HOW SOON WILL THE COUNCIL MAKE A DECISION?
IF THE COUNCIL DECIDES IN YOUR FAVOR
WIF THE COUNCIL DECIDES AGAINST YOU


Appeal Level 5: Your case may go to a Federal Court
HOW SOON WILL THE JUDGE MAKE A DECISION?

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 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?

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 2008 Medicare & You book. Please refer to your 2008 Medicare & You book for additional guidance on your appeal rights under Original Medicare. If you do not have a 2008 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 2008 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 spend waiting on the phone, in the waiting room, or in the exam room.
• Problems with getting appointments when you need them, or having to wait a long time for an appointment.
• Disrespectful or 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 expedite your request for an expedited coverage determination, organization determination, redetermination, or reconsideration.
• You believe our notices and other written materials are difficult to understand.
• Failure to give you a decision within the required timeframe.
• Failure to forward your case to the independent review entity if we do not give you a decision within the required timeframe.
• Failure to provide required notices.
• Failure to provide required notices that comply with CMS standards.

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

For quality of care problems, you may also complain to the QIO
If you are concerned about the quality of care you received under Medicare, including care during a hospital stay, you can also complain to an independent organization called the QIO. See Section 1 for more information about contacting your state-specific QIO.

Quality of care complaints filed with the QIO must be made in writing. A member who files a quality of care grievance with a QIO is not required to file the grievance within a specific time period. See Section 1 for more information about how to file a quality of care complaint with the QIO.

This section gives the rules for making complaints about Medicare services and payments in different types of situations. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your medical care as a UPREHS member. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from UPREHS Medicare Plans or penalized in any way if you make a complaint.

Please refer to Original Medicare rules in your 2008 Medicare & You book for additional guidance on your appeal rights under Original Medicare. If you do not have a 2008 Medicare & You book, please call Medicare at 1-800-633-4227 to get a copy. (See your 2008 UPREHS Prime Medicare Plan Benefit Guide for information about making complaints about your prescription drug plan.)

• 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.

Mail your UPREHS MSP payment appeal 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 2008 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.

RRailroad 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.

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

• Part 1. Complaints about what benefit or service we will provide you or what we will pay for (cover).
• Part 2. Complaints if you think you are being discharged from 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 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.

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 2008 Medicare & You book, and any amendments you may receive describe the benefits and services covered by 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).

You also have the right to have an attorney ask for an initial decision on your behalf. You can 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.

You can ask for a fast decision only if you or any doctor believe that waiting for a standard decision could seriously harm your health or your ability to function.

• 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.

1. For a decision about payment for care you already received.
   
   
   • We have 30 days to make a decision after we have received your request. However, if we need more information, we can take up to 30 more days. You will be told in writing when we make a decision. If we do not approve your request, we must tell you why, and tell you how you can appeal this decision. If you have not received an answer from us within 60 days of your request, you can appeal (also called reconsideration) this decision.
   
   
2. For a standard initial decision about medical care.
   
   
   • We have up to 14 calendar days to make a decision after we have received your request, but we will make it sooner if your health condition requires. However, we are allowed to take up to an additional 14 calendar days to make a decision if you request the additional time, or if we need more time to gather information that may benefit you. For example, we may need more time to get information that would help us approve your request for medical care (such as medical records). If we take additional days, we will notify you in writing. If you feel that we should not take additional days, you can make a specific type of complaint called a grievance. Section 10 of this booklet tells how to file a grievance. 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.
     
     
   • We will tell you in writing of our initial decision concerning the medical care you have requested. You will receive this notification when we make our decision, under the time frame explained above. If we do not approve your request, we must explain why, and tell you of your right to appeal our decision. Step 2 tells how to file this appeal.
     
     
   • If you have not received an answer from us within 14 days of your request, or by the end of an extended time period, you have the right to appeal.
     
     
3. For a fast decision about medical care.
   
   
   • If you receive a fast decision, we will give you our decision about your medical care within 72 hours after you or your doctor ask for a it — sooner if your health requires. However, we can take up to 14 more days to make this decision if we find that some information is missing which may benefit you, or if you need more time to prepare for this review. If you feel that we should not take any additional days, you file a fast grievance. Section 10 of this booklet tells how to file a grievance.
     
   • We will tell you our decision by phone as soon as we make the decision. If we deny any part of your request, we will send you a letter that explains the decision within 3 days of contacting you by phone. If we do not tell you about our decision within 72 hours (or by the end of any extended time period), you have the right to appeal. If we deny your request for a fast decision, you may file a fast grievance. 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.

Please call us at 1-800-547-0421 if you need help in filing your appeal. We give your request to different people than those who were involved in making the initial decision. This helps ensure that we give your request a fresh look. 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.

If your appeal concerns a decision we, or Original Medicare made about authorizing medical care, then you and/or your doctor will first need to decide whether you need a fast appeal. The procedures for deciding on a standard or a fast appeal are the same as those described for a standard or fast initial decision.

• 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, 795 North 400 West, Salt Lake City, UT 84103.

You may also send your appeal to the Railroad Retirement office. Please note that sending your appeal to this office instead of to us will cause a delay when we begin the appeal, since this office must forward your appeal request to us.

What if you want a “fast” appeal?
The rules about asking for a fast appeal are the same as the rules about asking for a fast 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.

How soon must we decide on your appeal?
How quickly the decision is made on your appeal depends on the type of appeal. Remember, UPREHS can only perform an appeal on a Medicare claim that was processed by us. 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.

1. For a decision about payment for care 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.
     
2. For a standard decision about medical care.
   • Remember, this must be care you want to receive from a UPREHS participating physician. After we receive your appeal, we have up to 30 days to make a decision, but will make it sooner if your health condition requires. 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. 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.
3. For a fast decision about medical care.
   • 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.

1. For a decision about payment for care you already received.
   • We must pay within 60 calendar days of the day we received your request for us to reconsider our initial 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.
2. For a standard decision about medical care.
   • We must authorize or provide you with the care you have asked for as no later than 30 days after we received your appeal. 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, we will direct you to the proper resource or you can call Medicare at 1-800-633-4227.
3. For a fast decision about medical care.
   • We must authorize or provide you with the care you have asked for within 72 hours of receiving your appeal — or sooner, if your health would be affected by waiting this long. 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.

1. For a decision about payment for care you already received.
   • We must send all the information about your appeal to the independent review organization within 60 calendar days from the date we received your Level 1 appeal.
2. For a standard decision about medical care.
   • We must send all of the information about your appeal to the independent review organization as quickly as your health requires, but no later than 30 days after we received your Level 1 appeal.
3. For a fast decision about medical care.
   • We must send all of the information about your appeal to the independent review organization within 24 hours of our decision.

1. For an appeal about payment for care, the independent review organization has up to 60 days to make a decision.
2. For a standard appeal about medical care, the independent review organization has up to 30 days to make a decision. However, it can take up to 14 more days if more information is needed and the extension will benefit you.
3. For a fast appeal about medical care, the independent review organization has up to 72 hours to make a decision. However, it can take up to 14 more days if more information is needed and the extension will benefit you.

1. For an appeal about payment for care, UPREHS HCPP or the responsible Original Medicare claims processor must pay within 30 days after receiving the decision.
2. For a standard appeal about medical care, UPREHS HCPP or Original Medicare must authorize the care you have asked for within 72 hours after receiving notice of the decision, or provide the care no later than 14 days after receiving the decision.
3. For a fast appeal about medical care, UPREHS HCPP, or Original Medicare must authorize or provide you with the care you have asked for within 72 hours of receiving the decision.

You must make a request for review by an Administrative Law Judge in writing within 60 days after the date you were notified of the decision made at Appeal Level 2. The deadline may be extended for good cause. You must send your written request to the ALJ Field Office that is listed in the decision you receive from the independent review organization. The Administrative Law Judge will not review the appeal if the dollar value of the medical claim does not meet the minimum requirement provided in the independent review organization's decision. If the dollar value is less than the minimum requirement, you may not appeal any further. During this review, you may present evidence, review the record, and be represented by counsel.

In order to request judicial review of your case, you must file a civil action in a United States District Court. The letter you get from the Medicare Appeals Council in Appeal Level 4 will tell you how to request this review. The Federal Court Judge will first decide whether to review your case.

If the contested amount meets the minimum requirement provided in the Medicare Appeals Council's decision, you, UPREHS HCPP or Original Medicare may ask a Federal Court Judge to review the case.

• 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 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 you get the notice 2 days before your coverage ends, you must be sure to make your request no later than noon of the day after you get the notice.
• If you get the notice and you have more than 2 days before your coverage ends, you must make your request no later than noon of the day before the date that your coverage ends.

After reviewing all the information, the QIO will give an opinion about whether it is medically appropriate to terminate your coverage on the date that has been set for you. The QIO will make this decision within one full day after it receives the information it needs to make a decision.

If you do not ask the QIO for a fast appeal by the deadline, you can ask Original Medicare for a fast appeal. How to ask them for a fast appeal is covered in Part 1 of this section.

If you ask Original Medicare for a fast appeal of your termination and you continue getting services from the SNF, HHA, or CORF, you run the risk of having to pay for the care you receive past your termination date. Whether you have to pay or not depends on the decision Original Medicare makes.

• 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