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Medicare Advantage 2017

Medicare Appeals, Grievances and Claims

Sometimes you might disagree or are not satisfied with the coverage decision that was made and need a more formal process to deal with this problem. Please refer to Chapter 9 of your Evidence of Coverage (EOC) for detailed information regarding Organization Determination, Appeal, and Grievance processes. You may also contact Customer Service with any questions or concerns about these processes.

There are 3 types of processes for handling problems and concerns:

  • Organization Determinations
  • Appeals
  • Grievances (Complaints)

Organization Determination

You have the right to ask Memorial Hermann Advantage to provide or pay for items or services you think should be covered, provided, or continued. This is called an "organization determination." You, your representative, or your doctor can ask your plan in advance to make sure that the service is covered or after payment of the services is denied.

An organization determination (referred to here as a coverage decision) is a decision Memorial Hermann Advantage makes about your benefits and coverage and whether we will pay for the medical services you or your doctor have requested. You can also contact us to ask for a coverage decision before you receive certain medical services. You might want to ask us to make a coverage decision beforehand if your doctor is unsure whether we will cover a particular medical service or if your doctor refuses to provide medical care you think you need.

A standard coverage decision means we will give you an answer within 14 days of receiving your request.

If you think your health could be seriously harmed or that you could lose your ability to function by waiting the standard 14 days for a decision, you can ask for an “expedited” (fast appeal) decision. We will give you an answer with 72 hours after we receive your request for a fast coverage decision.

To get a fast coverage decision, you must meet two requirements:

  • You must be asking for coverage for medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care you have already received.)
  • You must need a fast decision because using the standard deadlines could cause serious harm to your health or hurt your ability to function.

You, your representative, or your doctor can ask us for a coverage decision by calling, writing, or faxing your request to us. To request an Organization Determination you, your doctor, or your representative may:

  • Call:

    Customer Service HMO: (844) 550-6886 (TTY 711)
    Customer Service PPO: (844) 550-6896 (TTY 711)

  • Fax:

    HMO: (713) 338-5811
    PPO: (713) 338-5812

  • Write:

    Memorial Hermann Advantage
    929 Gessner Road
    Suite 1500
    Houston, TX 77024

Appeal

An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan. You can appeal if Medicare or your plan denies one of these:

  • Your request for a health care service, supply, item, or prescription drug that you think you should be able to get
  • Your request for payment for a health care service, supply, item, or prescription drug you already got
  • Your request to change the amount you must pay for a health care service, supply, item or prescription drug.

You can also appeal if Medicare or your plan stops paying providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need. If your health requires a quick response, you must ask for a ‘fast appeal.’ Memorial Hermann Advantage will review the Organization Determination we made to review if we were following the benefits and coverage properly. Once we have completed our review we will provide you with our decision in writing. If we do not approve all or part of your appeal, it will automatically go on to a Level 2 Appeal. The Level 2 Appeal is reviewed by an Independent Review Organization, an independent organization hired by Medicare. If you are not satisfied with the decision from the Level 2 Appeal, you may be able to continue with the appeals process if you meet the requirements. These additional appeal levels are explained in your Evidence of Coverage, Chapter 9.

How to request an appeal?

To file an Appeal you or your representative must contact us and provide the following information:

  • Name
  • Address
  • Member ID Number
  • Reason for appeal
  • Any additional supporting information or evidence

Your or your representative contact us via:

  • Phone (for expedited only):
    Customer Service HMO: (844) 550-6886 (TTY 711)
    Customer Service PPO: (844) 550-6896 (TTY 711)
  • Fax:

    HMO: (713) 338-5811
    PPO: (713) 338-5812

  • Write:

    Memorial Hermann Advantage
    929 Gessner Road
    Suite 1500
    Houston, TX 77024

Complaints and Grievance

You have the right to file a complaint if you have a problem or concern. A grievance is a complaint about the care or medical services you receive. The complaint process is for certain types of problems only. This includes problems related to quality of care, waiting times and customer service.

A grievance is any complaint, other than one that involves a request for an initial organization determination or an appeal as discussed in your Evidence of Coverage, Chapter 9 about determinations and appeals. A grievance can include quality of medical care, poor customer service, respecting your privacy, and waiting times. You or your representative may call Customer Service at the number listed below. We will try to resolve your grievance over the phone, however if we cannot resolve your grievance over the phone Memorial Hermann Advantage has a formal review procedure. We will document your grievance while speaking to you; however you may also submit a written grievance to the Appeals and Grievance Department which will be investigated within 30 days. If you file a written grievance, after our investigation is completed we will respond in writing to you.

If you have dissatisfaction with any aspect of your health care plan, customer care, your provider or treatment facility, you can submit a grievance. Grievances do not include claims or service denials, as those are classified as appeals.

To file a Grievance you or your representative may:

  • Call:
    Customer Service HMO: (844) 550-6886 (TTY 711)
    Customer Service PPO: (844) 550-6896 (TTY 711)
  • Fax:

    HMO: (713) 338-5811
    PPO: (713) 338-5812

  • Write:

    Memorial Hermann Advantage
    929 Gessner Road
    Suite 1500
    Houston, TX 77024

Appointing a Representative

You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. If you want someone to act for you as a representative, then you and that person must sign and date a statement that gives that person legal permission to be your representative for an appeal, a grievance or an initial determination. To appoint a representative, download and complete Medicare's Appointment of Representative Form. You may also complete the Appointment of Representative form on the medicare.gov website (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website).

Mail your completed Appointment of Representative Form to:

Memorial Hermann Advantage Enrollment
929 Gessner Road
Suite 1500
Houston, TX 77024

Quality of Care Problems

For quality of care complaints, you may also complain to the Quality Improvement Organization (QIO)

Complaints concerning the quality of care received under Medicare may be acted upon by Memorial Hermann Advantage under the grievance process, by an independent organization called the QIO, or by both. For example, if a member believes he/she is being discharged from the hospital too soon, the member may file a complaint with the QIO in addition to or in lieu of a complaint filed under Memorial Hermann Advantage grievance process. For any complaint filed with the QIO, Memorial Hermann Advantage will cooperate with the QIO in resolving the complaint. If you file with the QIO, Memorial Hermann Advantage must help the QIO resolve the grievance. Please refer to Chapter 2, Section 4, or your Evidence of Coverage for additional information about the Quality Improvement Organization.

Additional Resources

You may also file a complaint directly to Medicare by calling 1-800-Medicare or by visiting medicare.gov. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website.)