Appeals and Grievances

For a standard Level 1 Appeal, we will give you an answer as quickly as your health condition requires but no later than 30 calendar days after we receive your appeal if your appeal is about services you have not yet received. If your request is for a Medicare Part B prescription drug you have not yet received, we will give you our answer within 7 calendar days after we receive your appeal. We will give you an answer as quickly as your health condition requires but no later than 60 calendar days after we receive your appeal if your appeal is for reimbursement for medical care you have already received and paid for yourself.

However, if your appeal is about services you have not yet received and we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more calendar days to make our decision. We will let you know if we decide to do this. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. If you believe we should not take extra days, you can file a “fast” grievance, and we will give you an answer to your grievance within 24 hours. For more information about grievances, see Grievances (Complaints).

If we do not give you our answer by the deadlines noted above, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal. For more information about Level 2 Appeals, see What happens with a Level 2 Appeal for Medical Care?

If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 30 calendar days if your request is for a medical item or service, or within 7 calendar days if your request is for a Medicare Part B prescription drug.

If you requested us to pay you back for medical care you already received: If the independent review organization decides we should pay, we must send you or the provider the payment within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process after Level 2, we must send the payment you requested to you or to the provider within 60 calendar days. We must give you our answer within 60 calendar days after we receive your appeal.

If our answer is “NO” to all or part of what you requested, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal. See What happens with a Level 2 Appeal for Medical Care?.

If your health requires it, you can ask us for a “fast” appeal. To get a fast appeal, you must meet two requirements:

• You must be appealing a decision we made about coverage for medical care you have not yet received. You cannot ask for a fast appeal if your request is about medical care you have already received.
• Using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor tells us that your health requires a fast appeal, we will automatically give you a fast appeal.

If you ask for a fast appeal on your own without your doctor’s support, we will decide whether your health requires that we give you a fast appeal. If we decide your medical condition does not meet the requirements for a fast appeal, we will process your request as a standard appeal and notify you of our decision to process your request as a standard appeal by sending you a letter. Our letter will indicate that we will automatically give you a fast appeal if your doctor requests it. You will also be provided with information about your right to file a “fast” grievance about our decision to give you a standard appeal instead of a fast appeal. For more information about grievances, see Grievances (Complaints).

For a fast Level 1 Appeal, we will give you an answer as quickly as your health condition requires but no later than 72 hours after we receive your appeal. However, if we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more calendar days to make our decision. We will let you know if we decide to do this. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. If we do not give you our answer within 72 hours (or, if there was an extended review period, by the end of that period), we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal. For more information about Level 2 Appeals, see What happens with a Level 2 Appeal for Medical Care?.

If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 72 hours after we receive your appeal.

If our answer is “NO” to part or all of what you requested, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal. See What happens with a Level 2 Appeal for Medical Care?.

The Independent Review Organization will review your appeal. This organization is hired by Medicare and is not connected with Peoples Health and is not a government agency. We send the information about your appeal to the organization. You have the right to provide the organization with additional information to support your appeal.

If you had a standard Level 1 Appeal, you will have a standard Level 2 Appeal.

• The organization must give you an answer within 30 calendar days of when it receives your appeal. If your request is for a Medicare Part B prescription drug, the organization must give you an answer within 7 calendar days of when it receives your appeal.
• If the organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The Independent Review Organization can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug.

If you had a fast Level 1 Appeal, you will have a fast Level 2 Appeal.

• The organization must give you an answer within 72 hours of when it receives your appeal.
• If the organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The Independent Review Organization can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug.

If the organization’s answer is “YES” to all or part of what you requested for a standard appeal, we must authorize the coverage within 72 hours or provide the service within 14 calendar days after we receive its decision; and if the organization’s answer is “YES” to all or part of what you requested for a fast appeal, we must authorize the coverage within 72 hours after we receive its decision. If the organization’s answer is “YES” to all or part of a standard appeal request for a Medicare Part B prescription drug, we must authorize or provide coverage within 72 hours after we receive its decision; and if the organization’s answer is “YES” to all or part of a fast appeal request for a Medicare Part B prescription drug, we must authorize or provide the coverage within 24 hours after we receive its decision.

If the organization’s answer is “YES” to your request about a payment we denied for medical services, we are required to send the payment you requested within 30 calendar days to you or the provider.

If the organization’s answer is “NO” to part or all of what you requested, it means it agrees with us that your request or part of your request should not be approved. The organization will send you a letter explaining its decision and that tells you the dollar value that must be in dispute for you to continue with the appeals process. If your case meets these requirements, you decide if you would like to continue the appeals process.

There are three additional levels to the appeals process after a Level 2 Appeal, for a total of five levels of appeal. There is also a separate appeals process if you would like us to cover a longer inpatient hospital stay or would like us to keep covering home health care, skilled nursing facility services or comprehensive outpatient rehabilitation facility services.

For a standard Level 1 Appeal, we will give you an answer as quickly as your health condition requires but no later than 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 requires it.
• If we do not give you our answer within 7 calendar days, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal. See What happens with a Level 2 Appeal for Prescription Drugs?.

If you are requesting that we pay you back for a drug you have already bought, we must give you our answer within 14 calendar days after we receive your request. If we do not give you our answer within 14 calendar days, we are required to send your request to the Independent Review Organization as a Level 2 Appeal.

If you requested coverage for a drug and our answer is “YES,” we must provide the coverage we have agreed to provide as quickly as your health condition requires, but no later than 7 calendar days after we receive your appeal.

If you requested us to pay you back for a drug you already bought and our answer is “YES,” we are required to send you payment within 30 calendar days after we receive your appeal.

If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. This notice will also provide information on how to appeal your decision as a Level 2 Appeal. See What happens with a Level 2 Appeal for Prescription Drugs?.

If your health requires it, you can ask us for a “fast” appeal. To get a fast appeal, you must meet two requirements:

• You must be asking for a drug you have not yet received. You cannot ask for a fast appeal if you are asking us to pay you back for a drug you already bought.
• Using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor or other prescriber tells us that your health requires a fast appeal, we will automatically agree to give you a fast appeal.

If you ask for a fast appeal on your own without your doctor’s or other prescriber’s support, we will decide whether your health requires that we give you a fast appeal. If we decide your medical condition does not meet the requirements for a fast appeal, we will process your request as a standard appeal and notify you of our decision to process your request as a standard appeal by sending you a letter. Our letter will indicate that we will automatically give you a fast appeal if your doctor or other prescriber requests it. We will also provide you with information about your right to file a “fast” grievance about our decision to give you a standard appeal instead of a fast appeal. For more information about grievances, see Grievances (Complaints).

For a fast Level 1 Appeal, we will give you an answer as quickly as your health condition requires but no later than 72 hours after we receive your appeal. If we do not give you our answer within 72 hours, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal. See What happens with a Level 2 Appeal for Prescription Drugs?.

If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 72 hours after we receive your appeal.

If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why we said no and how to appeal our decision as a Level 2 Appeal. See What happens with a Level 2 Appeal for Prescription Drugs?.

If we say no to your appeal, you then choose whether to accept this decision or continue by submitting another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed. This organization is hired by Medicare and is not connected with Peoples Health and is not a government agency.

To file a Level 2 Appeal, you must contact the Independent Review Organization listed in the letter we sent you when we said “NO” to your Level 1 Appeal. This letter also includes instructions on how to file a Level 2 Appeal, including deadlines for contacting the organization. If you do file a Level 2 Appeal, we will send the information we have about your appeal to the organization. You have the right to provide the organization with additional information to support your appeal.

For a standard Level 2 Appeal, the organization must give you an answer within 7 calendar days of when it receives your appeal.

If your health requires it, you may ask the organization for a fast Level 2 Appeal. If the organization agrees to a fast appeal, it must give you an answer within 72 hours of when it receives your appeal.

If your appeal was for coverage of a drug and the organization’s answer is “YES” to all or part of what you requested, we must provide the drug coverage:

• Within 72 hours after we receive the organization’s decision if it was a standard Level 2 Appeal
• Within 24 hours after we receive the organization’s decision if it was a fast Level 2 Appeal

If your appeal was for us to pay you back for a drug you already bought and the organization’s answer is “YES” to all or part of what you requested, we must send payment to you within 30 calendar days after we receive the organization’s decision.

If the organization’s answer is “NO” to part or all of what you requested, it means it agrees with us that your request or part of your request should not be approved. The organization will send you a letter explaining its decision and that tells you the dollar value that must be in dispute for you to continue with the appeals process. If your case meets these requirements, you decide if you would like to continue the appeals process.

There are three additional levels to the appeals process after a Level 2 Appeal, for a total of five levels of appeal.

A grievance is any complaint (other than an organization determination or coverage determination) related to your health plan or health care provider, including problems related to quality of care, waiting times and customer service, among others. A grievance is not used for requesting a coverage decision for benefits, coverage or payment. You can find more information about coverage decisions on the Coverage Decisions page. For example, you would file a grievance if you:

• Are unhappy with the quality of care you have received
• Believe your privacy was not respected
• Are unhappy with or have experienced disrespect from a provider or our plan
• Are having difficulties scheduling a doctor’s appointment
• Are unhappy with the cleanliness or condition of a doctor’s office or network pharmacy
• Believe our plan has not given you a notice you are required to receive or gave you information you believe was hard to understand

You can also file a complaint if you think our plan is not responding quickly enough to or meeting deadlines for a coverage decision or appeal request.

For information on the total number of grievances, appeals or formulary exceptions submitted to Peoples Health, contact us.

We encourage you to first contact customer service if you are having one of these problems. We will try to resolve the grievance over the phone.

If you are not satisfied with our response or if we cannot resolve your grievance over the phone, or if you do not wish to call us, you may submit your grievance in writing. See the How does the grievance review process work? section.

Please note: Whether you call or write, you should contact customer service right away. Most grievances must be made within 60 days of the problem or event.

You may also submit a grievance to Medicare through its online Medicare Complaint Form.

The Peoples Health grievance review process is as follows:

1. We must receive your grievance within 60 calendar days of the event or incident you are complaining about.
   If something kept you from filing your complaint (you were sick, we provided incorrect information, etc.) let us know and we might be able to accept your complaint past 60 days. We will address your complaint as quickly as possible but no later than 30 days after receiving it. Sometimes we need additional information, or you may wish to provide additional information. If that occurs, we may take an additional 14 days to respond to your complaint. If the additional 14 days is taken, you will receive a letter letting you know. If your complaint is because we took 14 extra days to respond to your request for a coverage determination or appeal or because we decided you didn’t need a fast coverage decision or a fast appeal, you can file a fast complaint. We will respond to you within 24 hours of receiving your complaint.
2. If you are dissatisfied with the response to your grievance, you can request a review in writing. Your review request may include written information from you or any other party of interest. You must submit the review request within 60 calendar days of receiving the original resolution. Our appeals and grievances coordinators will direct your review request to the appropriate committee, which will reconsider your written grievance and respond to you in writing within 30 calendar days of receipt of your request for review. The plan can present your case to the committee on your behalf, or you may choose to present your case to the committee yourself.

See the Contact Information and Important Links, Documents and Forms section for contact information and forms you can use to submit a grievance.

If you are filing a grievance because we denied your request for a “fast” decision on an organization determination or coverage determination or a “fast” appeal, we will automatically give you a “fast” grievance. This means we will give you an answer to your grievance within 24 hours.

When you file a grievance, we will answer you right away if possible. Most grievances are answered within 30 calendar days. If we need more information and the delay is in your best interest, or if you ask for more time, we can take up to 14 more calendar days (44 days total) to answer your grievance. If we decide to take extra days, we will tell you in writing.