Appeals & Grievances

These processes have been approved by Medicare and Medi-Cal. Each process has a set of rules, procedures, and deadlines that must be followed by us and by you.

Sometimes it can be confusing to start or follow through the process for dealing with a problem. This can be especially true if you do not feel well or have limited energy. Other times, you may not have the knowledge you need to take the next step.
 

Let Member Services try to solve your problem first

Most problems can be resolved by one of our Member Services Representatives. If you have a problem, please call L.A. Care Cal MediConnect Plan Member Services first so that we may try to find a solution.

Phone: 1-888-522-1298 (TTY: 711)
If you have concerns, call L.A. Care Cal MediConnect Plan Member Services, 24 hours a day, 7 days a week, including holidays.

You can get help from the Cal MediConnect Ombuds Program

If you need help getting started, you can always call the Cal MediConnect Ombuds Program. The Cal MediConnect Ombuds Program can answer your questions and help you understand what to do to handle your problem. The Cal MediConnect Ombuds Program is not connected with us or with any insurance company or health plan. They can help you understand which process to use. The services are free. You can contact the Cal MediConnect Ombuds Program by:

Phone: 1-855-501-3077

You can get help from the Health Insurance Counseling and Advocacy Program (HICAP)

You can also call the Health Insurance Counseling and Advocacy Program (HICAP). The HICAP counselors can answer your questions and help you understand what to do to handle your problem. HICAP is not connected with us or with any insurance company or health plan. HICAP has trained counselors in every county, and services are free. You can contact the local HICAP office by:

Phone: 1-800-824-0780 or 1-213-383-4519 (TTY: 1-213-251-7920)

Getting help from Medicare

You can call Medicare directly for help with problems. Here are two ways to get help from Medicare, by:

Phone: 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048), 24 hours a day, 7 days a week.

Web: Visit the Medicare website at www.medicare.gov

Getting help from Medi-Cal

You can call the Cal MediConnect Ombuds Program directly for help with problems with Medi-Cal.
You can contact the Cal MediConnect Ombuds Program by:

Phone: 1-855-501-3077

Web: You can also visit the Office of the Patient Advocate website www.opa.ca.gov

You may also file a complaint with the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) for California, Livanta. You may contact the BFCC-QIO by:

Mail: Livanta
BFCC-QIO Program
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701

Phone: 1-877-588-1123 (TTY: 1-855-887-6668), 24 hours a day, seven days a week
Fax: Appeals – 1-855-694-2929; All other reviews – 1-844-420-6672

Appointing a Representative

Appointing a Representative

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a decision or make an appeal. There may be someone who is already legally authorized to act as your representative under State law. If you want a friend, relative, your doctor or other provider, or other person to be your representative, you can make this request by:

Phone: Call Member Services and ask for the Appointment of Representative Form, to give that person permission to act on your behalf.

Mail: You may also send a written statement authorizing the individual to act on your behalf. The form or statement must be signed by you and by the person who you would like to act on your behalf. You must give our Plan a copy of the signed form or statement indicating that the individual accepts the appointment. Please send the completed form or statement to:

L.A. Care Cal MediConnect Plan
Attn: Grievances & Appeals Unit
P.O. Box 811610
Los Angeles, CA 90081

Fax: Or fax the signed form or statement to 213-438-5748

You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of decision or appeal a decision.

Related documents:

Appointment of Representative Form (pdf)

Overview of Organization/Coverage Determinations & Appeals

The process for asking for coverage decisions and making appeals deals with problems related to your benefits and coverage. It also includes problems with payment. You are not responsible for Medicare costs except Part D co-pays.

What is a coverage decision?

A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay. If you or your doctor are not sure if a service, item, or drug is covered by Medicare or Medi-Cal, either of you can ask for a coverage decision before the doctor gives the service, item, or drug.

What is an appeal?

An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagree with our decision, you can appeal.

Getting help with coverage decisions and appeals

You can ask any of these people for help:

You can call us at Member Services at 1-888-522-1298 (TTY: 711).

Call the Cal MediConnect Ombuds Program for free help. The Cal MediConnect Ombuds Program helps people enrolled in Cal MediConnect with service or billing problems. The phone number is 1-855-501-3077.

Call the Health Insurance Counseling and Advocacy Program (HICAP) for free help. HICAP is an independent organization. It is not connected with this plan. The phone number is 1-800-824-0780 or 1-213-383-4519 (TTY: 1-213-251-7920).

Call your local county social services office for questions about coverage decisions for In-Home Supportive Services (IHSS). The phone number is 1-877-597-4777.

Talk to your doctor or other provider. Your doctor or other provider can ask for a coverage decision or appeal on your behalf. Talk to a friend or family member and ask him or her to act for you. You can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal. If you want a friend, relative, or other person to be your representative, call Member Services and ask for the “Appointment of Representative” form. You can also get the form on the Medicare website or under the “Appointing a Representative” section of this website. The form will give the person permission to act for you. You must give us a copy of the signed form.

You also have the right to ask a lawyer to act for you. You may call your own lawyer, or get the name of a lawyer from the local bar association or other referral service. Some legal groups will give you free legal services if you qualify. If you want a lawyer to represent you, you will need to fill out the Appointment of Representative form. However, you do not have to have a lawyer to ask for any kind of coverage decision or to make an appeal.

Problems about Services, Items, and Drugs (Not Part D Drugs)

How to ask for a coverage decision to get medical, behavioral health, or certain long-term services and supports

To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a decision.

You can contact us by:

Phone: 1-888-522-1298 (TTY: 711)
Fax: 1-213-438-5712
Mail: L.A. Care Cal MediConnect Plan
Attn: Member Services Department
1055 West 7th Street
Los Angeles, CA 90017

You can also mail or fax this completed form to the address and fax number on the form.

How long does it take to get a coverage decision?

It usually takes up to 14 calendar days after you asked. If we don’t give you our decision within 14 calendar days, you can appeal. Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days.

Can you get a coverage decision faster?

Yes. If you need a response faster because of your health, you should ask us to make a “fast coverage decision.” If we approve the request, we will notify you of our decision within 72 hours.
However, sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days.

Asking for a fast coverage decision:

If you request a fast coverage decision, start by calling or faxing our plan to ask us to cover the care you want. You can contact us by:

Phone: 1-8888-522-1298 (TTY: 711)
Fax: 1-213-438-5712
Mail: L.A. Care Cal MediConnect Plan
Attn: Member Services Department
1055 West 7th Street
Los Angeles, CA 90017

You can also have your doctor or your representative call us.

Here are the rules for asking for a fast coverage decision.

You must meet the following two requirements to get a fast coverage decision:

You can get a fast coverage decision only if you are asking for coverage for care or an item you have not yet received. (You cannot get a fast coverage decision if your request is about payment for care or an item you have already received.)


You can get a fast coverage decision only if the standard 14 calendar day deadline could cause serious harm to your health or hurt your ability to function.


If your doctor says that you need a fast coverage decision, we will automatically give you one:

If you ask for a fast coverage decision, without your doctor’s support, we will decide if you get a fast coverage decision.
If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. We will also use the standard 14 calendar day deadline instead.

This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. The letter will also tell how you can file a “fast complaint” about our decision to give you a standard coverage decision instead of the fast coverage decision you requested.

If the coverage decision is Yes, when will I get the service or item?

You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period.

If the coverage decision is No, how will I find out?

If the answer is No, we will send you a letter telling you our reasons for saying No. If we say no, you have the right to ask us to reconsider – and change – this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process.

Level 1 Appeal for Services, Items and Drugs (Not Part D Drugs)
What is a Level 1 Appeal?

A Level 1 Appeal is the first appeal to our plan. We will review our coverage decision to see if it is correct. The reviewer will be someone who did not make the original coverage decision. When we complete the review, we will give you our decision in writing. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal.

Note: You are not required to appeal to the plan for Medi-Cal services including long-term services and supports. If you do not want to first appeal to the plan, you can ask for a State Fair Hearing.

How do I make a Level 1 Appeal?

To start your appeal, you, your doctor or other provider, or your representative must contact us. You can ask us for a “standard appeal” or a “fast appeal.”

If you are asking for a standard appeal or fast appeal, make your appeal in writing or call us. You can contact us by:

Phone: 1-888-522-1298 (TTY: 711)
Fax: 1-213-438-5712
Mail: L.A. Care Cal MediConnect Plan
Attn: Appeals and Grievance Unit
P.O. Box 811610
Los Angeles, CA 90081

Can someone else make the appeal for me?

Yes. Your doctor or other provider can make the appeal for you. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative form. The form gives the other person permission to act for you. To get a Appointment of Representative form, call Member Services and ask for one, or visit the Medicare website or the “Appointing a Representative” section of this website. If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal.

How much time do I have to make an appeal?

You must ask for an appeal within 90 calendar days from the date on the letter we sent to tell you our decision.
If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of a good reason are: you had a serious illness, or we gave you the wrong information about the deadline for requesting an appeal.

When will I hear about a “standard” appeal decision?

We must give you our answer within 30 calendar days after we get your appeal. We will give you our decision sooner if your health condition requires us to. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter. If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.
If we do not give you an answer within 30 calendar days or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. You will be notified when this happens. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself.

If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 30 calendar days after we get your appeal.

If our answer is No to part or all of what you asked for, we will send you a letter. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself.

What happens if I ask for a fast appeal?

If you ask for a fast appeal, we will give you your answer within 72 hours after we get your appeal. We will give you our answer sooner if your health requires us to do so. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter. If we do not give you an answer within 72 hours or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. You will be notified when this happens. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself.

If our answer is Yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal.

If our answer is No to part or all of what you asked for, we will send you a letter. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself.

Will my benefits continue during Level 1 appeals?

During a Level 1 Appeal, you can keep getting all prior approved non-Part D benefits that we told you would be stopped or changed. This means that such benefits will continue to be provided to you and that we must continue to pay providers for providing such benefits during a Level 1 Appeal.

Level 2 Appeal for Services, Items, and Drugs (Not Part D Drugs)
If the plan says No at Level 1, what happens next?

If we say no to part or all of your Level 1 Appeal, we will send you a letter. This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal. If your problem is about a Medicare service or item, we will automatically send your case to Level 2 of the appeals process as soon as the Level 1 Appeal is complete. If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. The letter will tell you how to do this. Information is also below.

What is a Level 2 Appeal?

A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan. It is either an Independent Review Entity (IRE) or it is a Medi-Cal office.

My problem is about a Medi-Cal service or item. How can I make a Level 2 Appeal?

There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) State Fair Hearing or 2) Independent Medical Review (IMR).

1) State Fair Hearing
You can request a State Fair Hearing at any time for Medi-Cal covered services and items (including IHSS). When a Medi-Cal service you want is not approved by a Medi-Cal field office or L.A. Care Cal MediConnect Plan, you have the right to ask for a State Fair Hearing.

In most cases you have 90 days to ask for a State Fair Hearing after the “Your Hearing Rights” notice is mailed to you. You have a much shorter time to ask for a hearing if your benefits are being changed or taken away.
There are two ways to request a State Fair Hearing:

1. You may complete the "Request for State Fair Hearing" on the back of the notice of action. You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. Then you may submit your request one of these ways:

To the county welfare department at the address shown on the notice.
To the California Department of Social Services:

State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430

To the State Hearings Division at fax number 1-916-651-5210 or 1-916-651-2789.

2. You may make a toll-free call to request a State Fair Hearing at the following number. If you decide to make a request by phone, you should be aware that the phone lines are very busy.

Call the California Department of Social Services at 1-800-952-5253 (TTY: 1-800-952-8349).

2) Independent Medical Review (IMR)

You can ask for an Independent Medical Review (IMR) for Medi-Cal covered services and items (not including IHSS).
An IMR is a review of your case by doctors who are not part of our plan. If the IMR is decided in your favor, we must give you the service or item you requested. You pay no costs for an IMR.
You must apply for an IMR within 6 months after we send you a written decision about your appeal.

In most cases you will need to appeal to L.A. Care Cal MediConnect Plan first, and if we deny your appeal, you can then ask for an IMR by doctors who are not part of the plan within 6 months of our denial. However, if you think that appealing to our plan is not in your best interest, you may be able to have an IMR without appealing to us first.

To request an IMR:

Fill out the Complaint/Independent Medical Review (IMR) Application Form or call the DMHC Help Center at 1-888-466-2219 (TTY: 1-877-688-9891)
Attach copies of letters or other documents about the service or item that we denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents.

Mail or fax your form and any attachments to:

Help Center
Department of Managed Health Care
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
Fax: 1-916-255-5241

My problem is about a Medicare service or item. What will happen at the Level 2 Appeal?

An Independent Review Entity will do a careful review of the Level 1 decision, and decide whether it should be changed. You do not need to request the Level 2 Appeal. We will automatically send any denials (in whole or in part) to the Independent Review Entity. You will be notified when this happens. The Independent Review Entity is hired by Medicare and is not connected with this plan. You may ask for a copy of your file. The Independent Review Entity must give you an answer to your Level 2 Appeal within 30 calendar days of when it gets your appeal. This rule applies if you sent your appeal before getting medical services or items. However, if the Independent Review Entity needs to gather more information that may benefit you, it can take up to 14 more calendar days. If the IRE needs extra days to make a decision, it will tell you by letter. If you had “fast appeal” at Level 1, you will automatically have a fast appeal at Level 2. The review organization must give you an answer within 72 hours of when it gets your appeal. However, if the Independent Review Entity needs to gather more information that may benefit you, it can take up to 14 more calendar days. If the IRE needs extra days to make a decision, it will tell you by letter.

Will my benefits continue during Level 2 appeals?

If your problem is about a service or item covered by Medicare, your benefits for that service or item will not continue during the Level 2 appeals process with the Independent Review Entity. If your problem is about a service or item covered by Medi-Cal and you ask for a State Fair Hearing, your Medi-Cal benefits for that service or item will continue until a hearing decision is made. You must ask for a hearing before the date that your benefits are changed or taken away in order to get the same benefits until your hearing.

How will I find out about the decision?

If your Level 2 Appeal was a State Fair Hearing, the California Department of Social Services will send you a letter explaining its decision. If the State Fair Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. If the State Fair Hearing decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. We may stop any aid paid pending you are receiving. If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision. If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. You can still get a State Fair Hearing. If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize the medical care coverage within 72 hours or give you the service or item within 14 calendar days from the date we receive the IRE’s decision. If the Independent Review Entity says No to part or all of what you asked for, it means they agree with the Level 1 decision. This is called “upholding the decision.” It is also called “turning down your appeal.”

If the decision is No for all or part of what I asked for, can I make another appeal?

If your Level 2 Appeal was a State Fair Hearing, you may ask for a rehearing within 30 days after you receive the decision. You may also ask for judicial review of a State Fair Hearing denial by filing a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after you receive the decision. If your Level 2 Appeal was an Independent Medical Review, you can request a State Fair Hearing. If your Level 2 Appeal went to the Medicare Independent Review Entity, you can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. The letter you get from the IRE will explain additional appeal rights you may have.

Appeal a County’s decision regarding authorized hours of IHSS benefits

In-Home Supportive Services (IHSS) benefits are determined by your county social worker, not our plan. The county social worker will assess the types of services you need and the number of hours the county will authorize for each of these services. If you want to appeal the county’s decision regarding authorized hours for IHSS benefits, you must request a State Fair Hearing. You must file a request for a State Fair Hearing within 90 days after the date of the county’s action or inaction.

There are two ways to ask for a State Fair Hearing:

1. Fill out the back of the notice of action form and send it to the address indicated, or send a letter to:

State Hearings Division
Department of Social Services
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430

or

2. Call the California Department of Social Services at 1-800-952-5253 (TTY: 1-800-952-8349).

Payment Problems: How do I ask the plan to pay me back for medical services or items I paid for?

You are not responsible for Medicare costs except Part D co-pays. Under some circumstances, you may have cost sharing for Medi-Cal services, such as IHSS and nursing facility stays. If you are asking to be paid back, you are asking for a coverage decision. We will see if the service or item you paid for is a covered service or item, and we will check to see if you followed all the rules for using your coverage. If the medical care you paid for is covered and you followed all the rules, we will send you the payment for your medical care within 60 calendar days after we get your request. Or, if you haven’t paid for the service or item yet, we will send the payment directly to the provider. When we send the payment, it’s the same as saying Yes to your request for a coverage decision. If the medical care is not covered, or you did not follow all the rules, we will send you a letter telling you we will not pay for the service or item, and explaining why.

What if the plan says they will not pay?

If you do not agree with our decision, you can make an appeal. Follow the appeals process. When you are following these instructions, please note:

If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal.

If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal.

If we answer “no” to your appeal and the service or item is usually covered by Medicare, we will automatically send your case to the Independent Review Entity. We will notify you by letter if this happens.

If the IRE reverses our decision and says we should pay you, we must send the payment to you or to the provider 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 asked for to you or to the provider within 60 calendar days.

If the IRE says No to your appeal, it means they agree with our decision not to approve your request. (This is called “upholding the decision.” It is also called “turning down your appeal.”) The letter you get will explain additional appeal rights you may have. You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount.

If we answer “no” to your appeal and the service or item is usually covered by Medi-Cal, you can file a Level 2 Appeal yourself.

Problems with Part D Drugs

What to do if you have problems getting a Part D drug or you want us to pay you
back for a Part D drug

Your benefits as a member of our plan include coverage for many prescription drugs. Most of these drugs are “Part D drugs.” There are a few drugs that Medicare Part D does not cover but that Medi-Cal may cover. This section only applies to Part D drug appeals. The List of Covered Drugs (Drug List), includes some drugs with an asterisk (*). These drugs are not Part D drugs.

Can I ask for a coverage decision or make an appeal about Part D prescription
drugs?

Yes. Here are examples of coverage decisions you can ask us to make about your Part D drugs:

You ask us to make an exception such as:

Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs (Drug List)

Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get)

You ask us if a drug is covered for you (for example, when your drug is on the plan’s Drug List but we require you to get approval from us before we will cover it for you).

Please note: If your pharmacy tells you that your prescription cannot be filled, you will get a notice explaining how to contact us to ask for a coverage decision.

You ask us to pay for a prescription drug you already bought. This is asking for a coverage decision about payment.

If you disagree with a coverage decision we have made, you can appeal our decision.

What is an exception?

An exception is permission to get coverage for a drug that is not normally on our List of Covered Drugs, or to use the drug without certain rules and limitations. If a drug is not on our List of Covered Drugs, or is not covered in the way you would like, you can ask us to make an “exception.” When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception. Here are examples of exceptions that you or your doctor or another prescriber can ask us to make:

1. Covering a Part D drug that is not on our List of Covered Drugs (Drug List).
a. If we agree to make an exception and cover a drug that is not on the Drug List, you will need to pay the cost-sharing amount that applies to drugs in tier 2 for brand name drugs or tier 1 for generic drugs. You cannot ask for an exception to the co-payment or co-insurance amount we require you to pay for the drug.

2. Removing a restriction on our coverage. There are extra rules or restrictions that apply to certain drugs on our Drug List. The extra rules and restrictions on coverage for certain drugs include:

Being required to use the generic version of a drug instead of the brand name drug.
Getting plan approval before we will agree to cover the drug for you. (This is sometimes called “prior authorization.”)
Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called “step therapy.”)
Quantity limits. For some drugs, the plan limits the amount of the drug you can have.
If we agree to make an exception and waive a restriction for you, you can still ask for an exception to the co-pay amount we require you to pay for the drug.

Important things to know about asking for exceptions

Your doctor or other prescriber must tell us the medical reasons. Your doctor or other prescriber must give us a statement explaining the medical reasons for requesting an exception. Our decision about the exception will be faster if you include this information from your doctor or other prescriber when you ask for the exception. Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called “alternative” drugs. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception. We will say Yes or No to your request for an exception If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. If we say No to your request for an exception, you can ask for a review of our decision by making an appeal.

How to ask for a coverage decision about a Part D drug or reimbursement for
a Part D Drug, including an exception

Ask for the type of coverage decision you want. Call, write, or fax us to make your request. You, your representative, or your doctor (or other prescriber) can do this. You can call us at 1-888-522-1298 (TTY: 711). You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. You can also have a lawyer act on your behalf. You do not need to give your doctor or other prescriber written permission to ask us for a coverage decision on your behalf. If you want to ask us to pay you back for a drug, read Chapter 7, Section A of the Member Handbook. If you are requesting an exception, provide the “supporting statement.” Your doctor or other prescriber must give us the medical reasons for the drug exception. We call this the “supporting statement.” Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement.

If your health requires it, ask us to give you a “fast coverage decision”

We will use the “standard deadlines” unless we have agreed to use the “fast deadlines.” A standard coverage decision means we will give you an answer within 72 hours after we get your doctor’s statement. A fast coverage decision means we will give you an answer within 24 hours. You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.) You can get a fast coverage decision only if 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 coverage decision,” we will automatically agree to give you a fast coverage decision, and the letter will tell you that. If you ask for a fast coverage decision on your own (without your doctor’s or other prescriber’s support), we will decide whether you get a fast coverage decision. If we decide to give you a standard decision, we will send you a letter telling you that. The letter will tell you how to make a complaint about our decision to give you a standard decision. You can file a “fast complaint” and get a decision within 24 hours. If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).

Deadlines for a “fast coverage decision”

If we are using the fast deadlines, we must give you our answer within 24 hours. This means within 24 hours after we get your request. Or, if you are asking for an exception, 24 hours after we get your doctor’s or prescriber’s statement supporting your request. We will give you our answer sooner if your health requires us to. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, an outside independent organization will review your request and our decision. If our answer is Yes to part or all of what you asked for, we must give you the coverage within 24 hours after we get your request or your doctor’s or prescriber’s statement supporting your request. If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. The letter will also explain how you can appeal our decision.

Deadlines for a “standard coverage decision” about a drug you have not yet
received

If we are using the standard deadlines, we must give you our answer within 72 hours after we get your request or, if you are asking for an exception, after we get your doctor’s or prescriber’s supporting statement. We will give you our answer sooner if your health requires it. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review the decision. If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, your doctor’s or prescriber’s supporting statement. If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. The letter will also explain how you can appeal our decision.

Deadlines for a “standard coverage decision” about payment for a drug you have already bought

We must give you our answer within 14 calendar days after we get your request. If we do not meet this deadline, we will send your request to Level 2 of the appeals process. At level 2, an Independent Review Entity will review the decision. If our answer is Yes to part or all of what you asked for, we will make payment to you within 14 calendar days. If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. This statement will also explain how you can appeal our decision.

Level 1 Appeal for Part D drugs

To start your appeal, you, your doctor or other prescriber, or your representative must contact us. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. You may also ask for an appeal by calling us at 1-888-522-1298 (TTY: 711). If you want a fast appeal, you may make your appeal in writing or you may call us. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. For example, good reasons for missing the deadline would be if you have a serious illness that kept you from contacting us or if we gave you incorrect or incomplete information about the deadline for requesting an appeal. You can ask for a copy of the information in your appeal and add more information. You have the right to ask us for a copy of the information about your appeal. If you wish, you and your doctor or other prescriber may give us additional information to support your appeal.

If your health requires it, ask for a “fast appeal”

If you are appealing a decision our plan made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a “fast appeal.” The requirements for getting a “fast appeal” are the same as those for getting a “fast coverage decision” outlined in the section above under “Problems with Part D Drugs.”

Our plan will review your appeal and give you our decision

We take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said No to your request. We may contact you or your doctor or other prescriber to get more information.

Deadlines for a “fast appeal”

If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it. If we do not give you an answer within 72 hours, we will send your request on to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review our decision. If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal. If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No.

Deadlines for a “standard appeal”

If we are using the standard deadlines, we must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it. If you think your health requires it, you should ask for a “fast appeal.” If we do not give you a decision within 7 calendar days, we will send your request to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review our decision. If our answer is Yes to part or all of what you asked for: If we approve a request for coverage, we must give you the coverage as quickly as your health requires, but no later than 7 calendar days after we get your appeal. If we approve a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get your appeal request. If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No and tells how to appeal our decision.

Related Forms:

Request for Medicare Prescription Drug Determination Request Form (pdf)

The Medicare Prescription Drug Determination Request Form is not required to request a coverage decision. L.A. care is required to accept any request that is made in writing when made by a Member, a Member’s prescribing physician, or other prescriber, or a Member’s appointed representative. L.A. Care is prohibited from required a Member, physician or other prescriber to make a written request on a specific form. The written request can be mailed, delivered in person, or faxed to:

L.A. Care Cal MediConnect Plan
Attn: Pharmacy & Formulary
1055 West 7th Street
Los Angeles, CA 90017

Fax: 1-213-438-5776

Level 2 Appeal for Part D drugs

If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Entity will review our decision. If you want the Independent Review Entity to review your case, your appeal request must be in writing. The letter we send about our decision in the Level 1 Appeal will explain how to request the Level 2 Appeal. When you make an appeal to the Independent Review Entity, we will send them your case file. You have the right to ask us for a copy of your case file. You have a right to give the Independent Review Entity other information to support your appeal. The Independent Review Entity is an independent organization that is hired by Medicare. It is not connected with this plan and it is not a government agency. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. The organization will send you a letter explaining its decision.

Deadlines for “fast appeal” at Level 2

If your health requires it, ask the Independent Review Entity for a “fast appeal.” If the review organization agrees to give you a “fast appeal,” it must give you an answer to your Level 2 Appeal within 72 hours after getting your appeal request. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 24 hours after we get the decision.

Deadlines for “standard appeal” at Level 2

If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 72 hours after we get the decision. If the Independent Review Entity approves a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get the decision.

What if the Independent Review Entity says No to your Level 2 Appeal?

No means the Independent Review Entity agrees with our decision not to approve your request. This is called “upholding the decision.” It is also called “turning down your appeal.” If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another appeal at Level 3. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. The Level 3 Appeal is handled by an administrative law judge.

Asking us to cover a longer hospital stay

When you are admitted to a hospital, you have the right to get all hospital services that we cover that are necessary to diagnose and treat your illness or injury. During your hospital stay, your doctor and the hospital staff will be working with you to prepare for the day when you will leave the hospital. They will also help arrange for any care you may need after you leave.

  • The day you leave the hospital is called your “discharge date.” Our plan’s coverage of your hospital stay ends on this date.
  • Your doctor or the hospital staff will tell you what your discharge date is.

If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay. This section tells you how to ask.

Learning about your Medicare rights

Within two days after you are admitted to the hospital, a caseworker or nurse will give you a notice called An Important Message from Medicare about Your Rights. If you do not get this notice, ask any hospital employee for it. If you need help, please call Member Services (phone numbers are printed on the back cover of this booklet). You can also call 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048), 24 hours a day, 7 days a week. Read this notice carefully and ask questions if you don’t understand. The Important Message tells you about your rights as a hospital patient, including:
Your right to get Medicare-covered services during and after your hospital stay. You have the right to know what these services are, who will pay for them, and where you can get them. Your right to be a part of any decisions about the length of your hospital stay. Your right to know where to report any concerns you have about the quality of your hospital care. Your right to appeal if you think you are being discharged from the hospital too soon. You should sign the Medicare notice to show that you got it and understand your rights. Signing the notice does not mean you agree to the discharge date told to you by your doctor or hospital staff. Keep your copy of the signed notice so you will have the information in it if you need it. To look at a copy of this notice in advance, you can call Member Services at 1-888-522-1298 (TTY: 711). You can also call 1-800 MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048), 24 hours a day, 7 days a week. You can also see the notice online. If you need help, please call Member Services at 1-888-522-1298 (TTY: 711). You can also call 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048), 24 hours a day, 7 days a week.

Level 1 Appeal to change your hospital discharge date

If you want us to cover your inpatient hospital services for a longer time, you must request an appeal. A Beneficiary and Family-Centered Care Quality Improvement Organization will do the Level 1 Appeal review to see if your planned discharge date is medically appropriate for you.

To make an appeal to change your discharge date call the Livanta at: 1-877-588-1123 (TTY: 1-855-887-6668).

Call right away!

Call the Beneficiary and Family-Centered Care Quality Improvement Organization before you leave the hospital and no later than your planned discharge date. An Important Message from Medicare about Your Rights contains information on how to reach the Beneficiary and Family-Centered Care Quality Improvement Organization.

If you call before you leave, you are allowed to stay in the hospital after your planned discharge date without paying for it while you wait to get the decision on your appeal from the Beneficiary and Family-Centered Care Quality Improvement Organization.
If you do not call to appeal, and you decide to stay in the hospital after your planned discharge date, you may have to pay all of the costs for hospital care you get after your planned discharge date.
If you miss the deadline for contacting the Beneficiary and Family-Centered Care Quality Improvement Organization about
your appeal, you can make your appeal directly to our plan instead.

We want to make sure you understand what you need to do and what the deadlines are.

Ask for help if you need it. If you have questions or need help at any time, please call Member Services at 1-888-522-1298 (TTY: 711). You can also call the Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-824-0780 or 1-213-383-4519 (TTY: 1-213-251-7920) or the Cal MediConnect Ombuds Program at 1-855-501-3077.

Ask for a “fast review”

You must ask the Beneficiary and Family-Centered Care Quality Improvement Organization for a “fast review” of your discharge. Asking for a “fast review” means you are asking for the organization to use the fast deadlines for an appeal instead of using the standard deadlines.

What happens during the review?

The reviewers at the Beneficiary and Family-Centered Care Quality Improvement Organization will ask you or your representative why you think coverage should continue after the planned discharge date. You don’t have to prepare anything in writing, but you may do so if you wish.
The reviewers will look at your medical record, talk with your doctor, and review all of the information related to your hospital stay. By noon of the day after the reviewers tell us about your appeal, you will get a letter that gives your planned discharge date. The letter explains the reasons why your doctor, the hospital, and we think it is right for you to be discharged on that date.

What if the answer is Yes?

If the review organization says Yes to your appeal, we must keep covering your hospital services for as long as they are medically necessary.

What if the answer is No?

If the review organization says No to your appeal, they are saying that your planned discharge date is medically appropriate. If this happens, our coverage for your inpatient hospital services will end at noon on the day after the Beneficiary and Family-Centered Care Quality Improvement Organization gives you its answer. If the review organization says No and you decide to stay in the hospital, then you may have to pay the full cost of hospital care you get after noon on the day after the Beneficiary and Family-Centered Care Quality Improvement Organization gives you its answer. If the Beneficiary and Family-Centered Care Quality Improvement Organization turns down your appeal, and you stay in the hospital after your planned discharge date, then you can make a Level 2 Appeal.

Level 2 Appeal to change your hospital discharge date

If the Beneficiary and Family-Centered Care Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make a Level 2 Appeal. You will need to contact the Beneficiary and Family-Centered Care Quality Improvement Organization again and ask for another review.

Ask for the Level 2 review within 60 calendar days after the day when the Beneficiary and Family-Centered Care Quality Improvement Organization said No to your Level 1 Appeal. You can ask for this review only if you stayed in the hospital after the date that your coverage for the care ended.
You can reach the Livanta at: 1-877-588-1123 (TTY: 1-855-887-6668).

Reviewers at the Beneficiary and Family-Centered Care Quality Improvement Organization will take another careful look at all of the information related to your appeal.

Within 14 calendar days, the Beneficiary and Family-Centered Care Quality Improvement OrganizationBeneficiary and Family-Centered Care Beneficiary and Family-Centered Care Quality Improvement Organization reviewers will make a decision.

What happens if the answer is Yes?

We must pay you back for our share of the costs of hospital care you have received since noon on the day after the date of your first appeal decision. We must continue providing coverage for your inpatient hospital care for as long as it is medically necessary. You must continue to pay your share of the costs and coverage limitations may apply.

What happens if the answer is No?

It means the Quality Review Organization agrees with the Level 1 decision and will not change it. The letter you get will tell you what you can do if you wish to continue with the appeal process. If the Quality Review Organization turns down your Level 2 Appeal, you may have to pay the full cost for your stay after your planned discharge date.

What happens if I miss an appeal deadline?

If you miss appeal deadlines, there is another way to make Level 1 and Level 2 Appeals, called Alternate Appeals. But the first two levels of appeal are different.

Level 1 Alternate Appeal to change your hospital discharge date

If you miss the deadline for contacting the Beneficiary and Family-Centered Care Quality Improvement Organization, you can make an appeal to us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. During this review, we take a look at all of the information about your hospital stay. We check to see if the decision about when you should leave the hospital was fair and followed all the rules. We will use the fast deadlines rather than the standard deadlines for giving you the answer to this review. We will give you our decision within 72 hours after you ask for a “fast review.” If we say Yes to your fast review, it means we agree that you still need to be in the hospital after the discharge date. We will keep covering hospital services for as long as it is medically necessary. It also means that we agree to pay you back for our share of the costs of care you have received since the date when we said your coverage would end. If we say No to your fast review, we are saying that your planned discharge date was medically appropriate. Our coverage for your inpatient hospital services ends on the day we said coverage would end. If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you got after the planned discharge date. To make sure we were following all the rules when we said No to your fast appeal, we will send your appeal to the “Independent Review Entity.” When we do this, it means that your case is automatically going to Level 2 of the appeals process.

Level 2 Alternate Appeal to change your hospital discharge date

We will send the information for your Level 2 Appeal to the Independent Review Entity within 24 hours of when we give you our Level 1 decision. If you think we are not meeting this deadline or other deadlines, you can make a complaint. Section 10 of this chapter tells how to make a complaint. During the Level 2 Appeal, the Independent Review Entity reviews the decision we made when we said No to your “fast review.” This organization decides whether the decision we made should be changed. The Independent Review Entity does a “fast review” of your appeal. The reviewers give you an answer within 72 hours. The Independent Review Entity is an independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal of your hospital discharge. If the Independent Review Entity says Yes to your appeal, then we must pay you back for our share of the costs of hospital care you have received since the date of your planned discharge. We must also continue the plan’s coverage of your hospital services for as long as it is medically necessary. If this organization says No to your appeal, it means they agree with us that your planned hospital discharge date was medically appropriate. The letter you get from the Independent Review Entity will tell you what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal, which is handled by a judge.

Problems with Home Health Care, Skilled Nursing Care, or CORF

This section is about the following types of care only:

  • Home health care services (This does not include IHSS. For IHSS problems or complaints, see the section called “Problems about Services, Items, and Drugs (Not Part D Drugs).”
  • Skilled nursing care in a skilled nursing facility.
  • Rehabilitation care you are getting as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are getting treatment for an illness or accident, or you are recovering from a major operation.
  • With any of these three types of care, you have the right to keep getting covered services for as long as the doctor says you need it.
  • When we decide to stop covering any of these, we must tell you before your services end. When your coverage for that care ends, we will stop paying for your care.

If you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask for an appeal.

We will tell you in advance when your coverage will be ending

The agency or facility that is providing your care will give you a notice at least two days before we stop paying for your care. The written notice tells you the date when we will stop covering your care. The written notice also tells you how to appeal this decision.You or your representative should sign the written notice to show that you got it. Signing it does not mean you agree with the plan that it is time to stop getting the care. When your coverage ends, we will stop paying.

Level 1 Appeal to continue your care

If you think we are ending the coverage of your care too soon, you can appeal our decision. Before you start, understand what you need to do and what the deadlines are. Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do. There are also deadlines our plan must follow. (If you think we are not meeting our deadlines, you can file a complaint.) Ask for help if you need it. If you have questions or need help at any time, please call Member Services at 1-888-522-1298 (TTY: 711). Or call your State Health Insurance Assistance Program at 1-800-824-0780 or 1-213-383-4519 (TTY: 1-213-251-7920). During a Level 1 Appeal, The Beneficiary and Family-Centered Care Quality Improvement Organization will review your appeal and decide whether to change the decision we made. You can find out how to call them by reading the Notice of Medicare Non-Coverage.

What should you ask for?

Ask them for an independent review of whether it is medically appropriate for us to end coverage for your services.

What is your deadline for contacting this organization?

You must contact the Beneficiary and Family-Centered Care Quality Improvement Organization no later than noon of the day after you got the written notice telling you when we will stop covering your care. If you miss the deadline for contacting the Beneficiary and Family-Centered Care Quality Improvement Organization about your appeal, you can make your appeal directly to us instead.

What happens during the Beneficiary and Family-Centered Care Quality Improvement Organization's review?

The reviewers at the Beneficiary and Family-Centered Care Quality Improvement Organization will ask you or your representative why you think coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish. When you ask for an appeal, the plan must write a letter explaining why your services should end. The reviewers will also look at your medical records, talk with your doctor, and review information that our plan has given to them. Within one full day after reviewers have all the information they need, they will tell you their decision. You will get a letter explaining the decision.

What happens if the reviewers say Yes?

If the reviewers say Yes to your appeal, then we must keep providing your covered services for as long as they are medically necessary.

What happens if the reviewers say No?

If the reviewers say No to your appeal, then your coverage will end on the date we told you. We will stop paying our share of the costs of this care. If you decide to keep getting the home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date your coverage ends, then you will have to pay the full cost of this care yourself.

Level 2 Appeal to continue your care

If the Beneficiary and Family-Centered Care Quality Improvement Organization said No to the appeal and you choose to continue getting care after your coverage for the care has ended, you can make a Level 2 Appeal. You can ask the Beneficiary and Family-Centered Care Quality Improvement Organization to take another look at the decision they made at Level 1. If they say they agree with the Level 1 decision, you may have to pay the full cost for your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end. The Beneficiary and Family-Centered Care Quality Improvement Organization will review your appeal and decide whether to change the decision we made. You can find out how to call them by reading the Notice of Medicare Non-Coverage. Ask for the Level 2 review within 60 calendar days after the day when the Beneficiary and Family-Centered Care Quality Improvement Organization said No to your Level 1 Appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended. Reviewers at the Beneficiary and Family-Centered Care Quality Improvement Organization will take another careful look at all of the information related to your appeal. The Beneficiary and Family-Centered Care Quality Improvement Organization will make its decision within 14 calendar days.

What happens if the review organization says Yes?

We must pay you back for our share of the costs of care you have received since the date when we said your coverage would end. We must continue providing coverage for the care for as long as it is medically necessary.

What happens if the review organization says No?

It means they agree with the decision they made on the Level 1 Appeal and will not change it. The letter you get will tell you what to do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by a judge.

What if you miss the deadline for making your Level 1 Appeal?

If you miss appeal deadlines, there is another way to make Level 1 and Level 2 Appeals, called Alternate Appeals. But the first two levels of appeal are different.

Level 1 Alternate Appeal to continue your care for longer

If you miss the deadline for contacting the Beneficiary and Family-Centered Care Quality Improvement Organization, you can make an appeal to us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. During this review, we take a look at all of the information about your hospital stay. We check to see if the decision about when your services should end was fair and followed all the rules. We will use the fast deadlines rather than the standard deadlines for giving you the answer to this review. We will give you our decision within 72 hours after you ask for a “fast review.” If we say Yes to your fast review, it means we agree that we will keep covering your services for as long as it is medically necessary. It also means that we agree to pay you back for our share of the costs of care you have received since the date when we said your coverage would end. If we say No to your fast review, we are saying that stopping your services was medically appropriate. Our coverage ends as of the day we said coverage would end. If you continue getting services after the day we said they would stop, you may have to pay the full cost of the services. To make sure we were following all the rules when we said No to your fast appeal, we will send your appeal to the “Independent Review Entity.” When we do this, it means that your case is automatically going to Level 2 of the appeals process.

Level 2 Alternate Appeal to continue your care for longer

We will send the information for your Level 2 Appeal to the Independent Review Entity within 24 hours of when we give you our Level 1 decision. If you think we are not meeting this deadline or other deadlines, you can make a complaint. During the Level 2 Appeal, the Independent Review Entity reviews the decision we made when we said No to your “fast review.” This organization decides whether the decision we made should be changed. The Independent Review Entity does a “fast review” of your appeal. The reviewers give you an answer within 72 hours. The Independent Review Entity is an independent organization that is hired by Medicare. This organization is not connected with our plan, and it is not a government agency. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. If this organization says Yes to your appeal, then we must pay you back for our share of the costs of care. We must also continue the plan’s coverage of your services for as long as it is medically necessary. If this organization says No to your appeal, it means they agree with us that stopping coverage of services was medically appropriate. The letter you get from the Independent Review Entity will tell you what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal, which is handled by a judge.

Taking your appeal beyond Level 2

Next steps for Medicare services and items

If you made a Level 1 Appeal and a Level 2 Appeal for Medicare services or items, and both your appeals have been turned down, you may have the right to additional levels of appeal. The letter you get from the Independent Review Entity will tell you what to do if you wish to continue the appeals process. Level 3 of the appeals process is an Administrative Law Judge (ALJ) hearing. If you want an ALJ to review your case, the item or medical service you are requesting will have to meet a minimum dollar amount. If the dollar value is less than the minimum level, you cannot appeal any further. If the dollar value is high enough, you can ask an ALJ to hear your appeal. If you do not agree with the ALJ’s decision, you can go to the Medicare Appeals Council. After that, you may have the right to ask a federal court to look at your appeal. If you need assistance at any stage of the appeals process, you can contact the Cal MediConnect Ombuds Program at 1-855-501-3077.

Next steps for Medi-Cal Services and Items

You also have more appeal rights if your appeal is about services or items that might be covered by Medi-Cal. If you do not agree with the State Fair Hearing decision and you want another judge to review it, you may request a rehearing and/or seek judicial review.

To request a rehearing, mail a written request (a letter) to:

The Rehearing Unit
744 P Street, MS 19-37
Sacramento, CA 95814

This letter must be sent within 30 days after you receive your decision. In your rehearing request, state the date you received your decision and why a rehearing should be granted. If you want to present additional evidence, describe the additional evidence and explain why it was not introduced before and how it would change the decision. You may contact Legal Services for assistance.
To ask for judicial review, you must file a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after receiving your decision. File your petition in the Superior Court for the county named in your decision. You may file this petition without asking for a rehearing. No filing fees are required. You may be entitled to reasonable attorney’s fees and costs if the Court issues a final decision in your favor. If a rehearing was heard and you do not agree with the decision from the rehearing, you may seek judicial review but you cannot request another rehearing.

Making a Complaint

What kinds of problems should be complaints?

The complaint process is used for certain types of problems only, such as problems related to quality of care, waiting times, and customer service. Here are examples of the kinds of problems handled by the complaint process.

Complaints about quality

You are unhappy with the quality of care, such as the care you got in the hospital.

Complaints about privacy

You think that someone did not respect your right to privacy, or shared information about you that is confidential.

Complaints about poor customer service

A health care provider or staff was rude or disrespectful to you. L.A. Care Cal MediConnect Plan staff treated you poorly. You think you are being pushed out of the plan.

Complaints about physical accessibility

You cannot physically access the health care services and facilities in a doctor or provider’s office.

Complaints about waiting times

You are having trouble getting an appointment, or waiting too long to get it. You have been kept waiting too long by doctors, pharmacists, or other health professionals or by Member Services or other plan staff.

Complaints about cleanliness

You think the clinic, hospital or doctor’s office is not clean.

Complaints about language access

Your doctor or provider does not provide you with an interpreter during your appointment.

Complaints about communications from us

You think we failed to give you a notice or letter that you should have received. You think the written information we sent you is too difficult to understand.

Complaints about the timeliness of our actions related to coverage decisions or appeals

You believe that we are not meeting our deadlines for making a coverage decision or answering your appeal. You believe that, after getting a coverage or appeal decision in your favor, we are not meeting the deadlines for approving or giving you the service or paying you back for certain medical services. You believe we did not forward your case to the Independent Review Entity on time.

Details and deadlines

Call Member Services at 1-888-522-1298 (TTY: 711). Complaints related to Medicare Part D must be made within 60 calendar days after you had the problem you want to complaint about. All other complaints must be filed with us or the provider within 180 calendar days from the day the incident occurred that caused you to be dissatisfied. If there is anything else you need to do, Member Services will tell you. You can also write your complaint and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. You can make a complaint if we have asked to delay a decision for an appeal. We will automatically give you a “fast complaint” and respond to your complaint in 24 hours. If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast complaint” and respond to your complaint within 24 hours. If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, you can request a “fast complaint” and we will respond within 72 hours. Most complaints are answered in 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 calendar days total to your complaint. If we do not agree with some or all of your complaint we will tell you and give you our reasons. We will respond whether we agree with the complaint or not.

You can file complaints with the Office of Civil Rights

If you have a complaint about disability access or about language assistance, you can file a complaint with the Office of Civil Rights at the Department of Health and Human Services 1-800-368-1019 (TTY: 1-800-537-7697). You may also have rights under the Americans with Disability Act and under Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, all other laws that apply to organizations that get Federal funding and any other laws and rules that apply for any other reason. You can contact the Cal MediConnect Ombuds Program for assistance.

You can make complaints about quality of care to the Beneficiary and Family-Centered Care Quality Improvement Organization

When your complaint is about quality of care, you also have two choices: If you prefer, you can make your complaint about the quality of care directly to the Beneficiary and Family-Centered Care Quality Improvement Organization (without making the complaint to us). Or you can make your complaint to us and also to the Beneficiary and Family-Centered Care Quality Improvement Organization. If you make a complaint to this organization, we will work with them to resolve your complaint. The Beneficiary and Family-Centered Care Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients. The phone number for the Beneficiary and Family-Centered Care Quality Improvement Organization is 1-866-800-8749 (TTY: 1-800-881-5980).

You can tell Medicare about your complaint

You can also send your complaint to Medicare through the Medicare Complaint Form. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. The call is free.

You can tell Medi-Cal about your complaint

The Cal MediConnect Ombuds Program also helps solve problems from a neutral standpoint to make sure that our members receive all the covered services that we are required to provide. The Cal MediConnect Ombuds Program is not connected with us or with any insurance company or health plan. The phone number for the Cal MediConnect Ombuds Program is 1-855-501-3077. The services are free.

Getting more Information

Getting more Information

For help or more information, contact Member Services by:

Phone: 1-888-522-1298 (TTY/TDD 711), 24 hours a day, 7 days a week, including holidays.

How to Request an Aggregate Number of Complaints (Grievances), Appeals, and Exceptions

You can request an aggregate number of complaints (grievances), appeals, and exceptions filed with L.A. Care Cal MediConnect by contacting us. If you request that the information be sent to you in writing, the information will be mailed to you within seven (7) to ten (10) business days.

You can contact Member Services by:

Phone: 1-888-522-1298 (TTY/TDD 711), 24 hours a day, 7 days a week, including holidays.

Fax: Submit written requests to 1-213-438-5748

Mail: Submit written requests to:

L.A. Care Health Plan
Attn: Grievance and Appeals Unit
P.O. Box 811610
Los Angeles, CA 90081

 

H8258_15129_2015CMC
CMS Approved
Updated 06/14/2016

 

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