What is an appeal?
An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services and/or prescription drugs or payment for services and/or prescription drugs you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our plan doesn’t pay for a drug/item/service you think you should be able to receive.
How long is the appeal process?
Memorial Hermann Advantage has both standard and fast (sometimes called expedited) appeal procedures. When requesting an appeal, you, your doctor, or appointed representative should let us know which of the two decision timeframes you need.
Standard Appeal – When we review a standard appeal, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for a “fast” appeal.
Fast Appeal – When we review a fast appeal, we must give you our answer within 72 hours after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so.
You can ask for a fast appeal only if you or your doctor believe that waiting for a standard appeal could seriously harm your health or your ability to function. Fast appeals apply only to requests for Medicare prescription drugs (Medicare Part D) that you have not received yet. You cannot get a fast appeal if you are requesting payment for a Medicare prescription drug (Medicare Part D) that you already received.
You, your doctor or your appointed representative must request an appeal (request for redetermination) within 60 days from the date of the notice of the adverse coverage determination (date printed or written on the notice). There are three ways you may request your standard or fast appeal. For more detailed information refer to Chapter 9 of your Evidence of Coverage.
What happens after I request a standard appeal?
Memorial Hermann Advantage will review the standard appeal (request for redetermination) and will provide you notice of our decision in writing (and process the change if favorable) as expeditiously as your health condition requires but no later than 7 calendar days of receipt of the appeal request. If Memorial Hermann Advantage decides that the time frame for the standard appeals process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited.
What happens after I request a fast (expedited) appeal?
If Memorial Hermann Advantage decides that the time frame for the standard appeals process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited. A request made or supported by your prescribing physician will be expedited if the physician indicates that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function. When an appeal request meets criteria for expedited processing, Memorial Hermann Advantage must provide you and your prescribing physician notice of its decision (and effectuate the change if favorable) as expeditiously as your health condition requires, but no later than 72 hours after receiving the request.
If additional medical information is required to process the request, Memorial Hermann Advantage must request it within 24 hours of receiving the fast appeal request. Even if additional information is required, Memorial Hermann Advantage must still issue notice of the decision within the 72-hour timeframe.
If Memorial Hermann Advantage determines that your request is not time-sensitive, where your health is not seriously jeopardized, Memorial Hermann Advantage will notify you verbally and in writing and will automatically begin processing your request under the standard appeals process. If you disagree and believe the review should be expedited, you may file an expedited grievance with Memorial Hermann Advantage. The written notice will include instructions on how to file an expedited grievance. You have the right to resubmit your request for an expedited appeal with your prescribing physicians support.
Your prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. You can appoint a representative to act on your behalf by providing us a completed Appointment of Representative Form.
If you disagree with a decision Memorial Hermann Advantage made regarding your appeal (request for redetermination), you may file an appeal with an outside entity. For further information regarding appeals, refer to Chapter 9 of your Evidence of Coverage or call Member Services at (855) 645-8448 (TTY 711). Hours of operation are 7 days a week from 8 a.m. to 8 p.m. (CST) during October 1 – March 31 and Monday – Friday from 8 a.m. to 8 p.m. (CST) during April 1 – September 30.
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 are dissatisfied 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:
If you need someone to file a grievance, coverage determination or appeal on your behalf, you can name a relative, friend, advocate, doctor or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.
If you want to appoint a representative, download Medicare's Appointment of Representative Form. You may also complete the Appointment of Representative form on medicare.gov (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website) website and mail it to:
Memorial Hermann Advantage Enrollment
929 Gessner Road
Houston, TX 77024
Download the Medical Power of Attorney Form.
CMS' Best Available Evidence policy (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website). 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.)