A plan member (or the member’s appointed representative) may file an appeal if Peoples Health makes a coverage decision for medical care coverage or prescription drug coverage and the member is not satisfied with the decision. A coverage decision is a decision we make about the member’s benefits and coverage or about the amount we will pay for the member’s medical services or prescription drugs (including whether particular medical care or prescription drugs are covered, as well as the way in which they are covered and how they are paid for). A coverage decision involving medical care (including for Part B prescription drugs) is called an organization determination; a coverage decision involving Part D prescription drugs, is called a coverage determination. An appeal is a way of asking us to review and change a coverage decision we have made.
A provider can request a Level 1 Appeal (the first level of appeal) on a member’s behalf. To do so, the provider must first notify the member of the intent to submit an appeal. In certain circumstances, Peoples Health is obligated to verify with the member that notification was received about the provider’s intent to appeal.
Appeals are classified as “standard” or “fast.” The timeline for submitting an appeal varies on whether it is a standard or expedited appeal request and whether it is a medical appeal (including for Part B prescription drugs) or a Part D prescription drug appeal. Fast appeals can only be made when the member has not yet received the care or drug in question and when using the standard appeal deadline could cause serious harm to the member’s health or ability to function. If a provider tells us that a member’s health requires a fast appeal, we will give the member a fast appeal. For all timelines listed below, we will give an answer sooner than the timeline listed if the member’s health requires it.
- Standard appeals for medical services must be submitted in writing within 60 calendar days from the date on the written notice we sent denying the coverage decision request. An answer to a standard appeal for medical services will be provided no later than 30 calendar days after we receive the appeal if the appeal is about services not yet received, and no later than 60 calendar days after we receive the appeal if it is about services already received; however, if we need to gather more information that may benefit the member, or if the member or provider submitting the appeal asks for more time, we can take up to 14 more calendar days.
- Fast appeals for medical services must be submitted by phone or in writing within 60 calendar days from the date on the written notice we sent denying the coverage decision request. An answer to a fast appeal for medical services will be provided no later than 72 hours after we receive the appeal; however, if we need to gather more information that may benefit the member, or if the member or provider submitting the appeal asks for more time, we can take up to 14 more calendar days.
- Standard appeals for Part D prescription drugs must be submitted in writing to OptumRx Part D Appeals and Grievance Department, P.O. Box 6103, MS CA 124-0197, Cypress, CA 90630-0023, within 60 calendar days from the date on the written notice we sent denying the coverage decision request. An answer to a standard appeal for Part D prescription drugs will be provided no later than seven calendar days after we receive the appeal.
- Fast appeals for Part D prescription drugs must be submitted by phone or in writing to OptumRx Part D Appeals and Grievance Department, at 1-866-553-5705 or P.O. Box 6103, MS CA 124-0197, Cypress, CA 90630-0023, within 60 calendar days from the date on the written notice we send to the member denying the coverage decision request. An answer to a fast appeal for Part D prescription drugs will be provided no later than 72 hours after we receive the appeal.
When an appeal is submitted, we review the coverage decision we made to see if we followed all of the rules properly. When we complete the review, we give the member our decision.
If we say no to all or part of the Level 1 appeal, the member (or the member’s appointed representative) can file a Level 2 appeal (appeals for medical care coverage are automatically sent to Level 2; for prescription drug coverage appeals, the member can elect to go to a Level 2 appeal). The Level 2 appeal is conducted by an independent organization not connected to our plan. If the member is not satisfied with the decision at the Level 2 appeal, the member may be able to continue through several more levels of appeal if the case meets certain requirements. For complete details about appeals, refer to a plan’s Evidence of Coverage.