APPEALS AND GRIEVANCES - From wellcare Insurance

The Plan maintains a member complaint system that includes grievance and appeals processes for Medicare Advantage members.

An appeal is a request for review of an action taken by or on behalf of the Plan. A member, a member’s representative with the member’s written consent, or a provider acting on behalf of the member and may file an
appeal.

Example of actions include but are not limited to the following:
 Denial or limited authorization of a requested service, including the type or level of service;
 The reduction, suspension or termination of a previously authorized service;
 The denial, in whole or in part, of payment for a service;
 The denial or limited authorization of a requested medication;
 The failure to provide services in a timely manner, as defined by the state.
 

A grievance is any complaint or dispute other than one involving an organization determination expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services regardless of whether any remedial action can be taken. A member or a member’s representative, acting on behalf of the member and with the member’s written consent, may file a grievance. Possible subjects for grievances include but are not limited to the following:

 Quality of care of services provided;
 Rudeness of the provider; or

 Failure to respect the member’s rights.
 

The Plan ensures that decision-makers on grievances and appeals are not involved in previous levels of review or decision-making. These decision-makers are health care professionals with clinical expertise in treating the
member’s condition or disease or have sought advice from providers with expertise in the field of medicine related to the request when making decisions on any of the following:
 

 An appeal of a denial based on lack of medical necessity.
 A grievance regarding denial of expedited resolution of an appeal.
 A grievance or appeal involving clinical issues

Posted in: insurance appeal basics