Coverage Decisions, Appeals and Grievances

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Sometimes we must make decisions about your benefits and coverage or about how much we’ll pay for a medical service or a prescription drug. These decisions are called coverage decisions or coverage determinations. Find out more about coverage decisions here.

If at any time we decide not to cover a service or drug (called a denial), you have the right to appeal our decision. When you file an appeal, you’re asking us to look again at your situation and reconsider our decision. Go to the Appeals section for more information on filing an appeal.

There may be times when you are unhappy with the plan or a provider. When that happens, you should tell us about the problem or file a grievance. A grievance is really a formal complaint, asking us to help solve an issue. For more about grievances, visit the Grievance section.

You, your provider, or another person on your behalf can request an organization determination, an appeal or a grievance. If you want to appoint a representative to act for you, you’ll need to name a representative in writing. You may download and fill out an Appointment of Representative form.  Call Member Services for more information or to request a form.

Coverage decisions

Whenever we decide what medical services are covered for you or how much we pay for those services, we’re making a coverage decision or organizational determination.

You can ask for a coverage decision by phone or in writing:

Call: 1-800-424-4495 (TTY 711)

Write to:

MCC of VA (HMO SNP)
Attn: Member Services
58 Charles Street
Cambridge, MA 02141

What happens next?

When we receive your request, we’ll tell you our decision within 14 working days. If your health requires a fast decision, we’ll answer within 72 hours.

In order to get a fast decision, both of the following must be true:

  • The request must be for medical care you have not yet received.
  • Using the standard deadline could cause serious harm to your health or hurt your ability to function.
    • If your doctor tells us your health requires a fast decision, we will automatically answer within 71 hours.
    • If you ask for a fast decision without your doctor’s support, we will decide whether to make a fast decision. If we say no, you can appeal.

Coverage decisions for Part D drugs

You can request a Part D coverage determination online or in writing:

MCC of VA (HMO SNP)
Attn: Pharmacy Department
58 Charles Street
Cambridge, MA 02141
FAX: 1-888-251-7823

We’ll answer your request for Part D prescription drugs within 72 hours of receiving your request. If you need a fast decision, we’ll answer within 24 hours.

Appeals (redeterminations)

If we make a coverage decision you aren’t satisfied with, you have the right to appeal that decision. Similarly, if we deny your request for a specific drug, you may appeal our decision. You, your doctor or your authorized representative must file an appeal within 60 days of receiving our coverage decision (organizational determination).

To request an appeal for medical care of service, you may file orally or in writing:

  • To file by phone, call 1-800-424-4495 (TTY 711)
  • To file in writing, send your request to:

MCC of VA (HMO SNP)
Attn: Appeals
58 Charles Street
Cambridge, MA 02141

Or you may fax your request to 1-855-838-7998.

To file an appeal about a Part D decision, you or your doctor must complete a Medicare Part D Redetermination Request Form online or by mail:

MCC of VA (HMO SNP)
Attn: Pharmacy
58 Charles Street
Cambridge, MA 02141

What happens next?

Standard appeals: We must give you an answer within 30 calendar days of receiving your appeal if your appeal is about a service you have not yet received. If your health condition request a faster decision, we will give you a fast appeal.

Fast appeals: We will make a decision on a fast appeal within 72 hours after we receive your appeal. To get a fast appeal, both of the following must be true:

  • The request must be for medical care you have not yet received.
  • Using the standard deadline could cause serious harm to your health or hurt your ability to function.
    • If your doctor tells us your health requires a fast decision, we will automatically answer within 72 hours.
    • If you ask for a fast decision without your doctor’s support, we will decide whether to make a fast decision. If we say no, you can appeal.

If we answer yes to part or all of the service or drug you requested, we must authorize or provide the coverage within 30 days of receiving your appeal.

If we answer no to part or all of the service or drug you requested, we will send you a written denial notice. We will also automatically send your appeal to the Independent Review Organization for another review.

Grievances

A grievance is a type of complaint you make about a problem or issue you have with our plan or a network provider. Typically, complaints are filed for things like:

  • Problems with the quality of care during a hospital stay
  • Wait times that are too long (for prescriptions, medical appointments, etc.)
  • Dissatisfaction with a provider’s behavior

These complaints do not involve coverage or payment decisions.

You must file your complaint within 60 days of the event or incident. To file a complaint, contact us as soon as possible – by phone or in writing.

  • To file by phone, call 1-800-424-4495 (TTY 711)
  • To file in writing, send your request to:

MCC of VA (HMO SNP)
Attn: Member Services
58 Charles Street
Cambridge, MA 02141

What happens next?

If possible, we will answer you right away. Most complaints are answered in 30 calendar days. But if we need more information and a delay is in your best interests, we can take up to 14 more calendar days. You may also ask us for an extension if you need more time to gather the information.

If you complain by phone, we may be able to give you answer immediately. If your health condition requires us to answer quickly, we will do so.

You don’t have to wait until we answer your complaint. You may also file a complaint with the Quality Improvement Organization, called Livanta. To file a complaint with Livanta, call 1-888-396-4646 (TTY 1-888-985-2660) Monday through Friday from 9 a.m. to 5 p.m., and 11 a.m. to 3 p.m. on weekends and holidays.

For more information about Livanta, refer to your Evidence of Coverage.

You may file a complaint with Medicare. You can give feedback or file a complaint at any time about your MCC of VA (HMO SNP) plan using the Medicare Complaint Form. (note: by clicking this link you’ll be leaving the MCC of VA (HMO SNP) website.)

The Centers for Medicare & Medicaid Services values your feedback and will use it to improve the quality of the Medicare program. If you have any other feedback or concerns, or if this is an urgent matter, please call 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048).

You may also contact the Office of the Medicare Ombudsman (OMO). The OMO helps you with complaints, grievances and information requests. For more information about the OMO, visit their website at www.medicare.com.