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Grievance, Coverage Determination and Appeal Processes

Grievance, Coverage Determination and Appeal Processes

This is a summary of RMHP’s grievance, coverage determination (including exceptions) and appeals processes.

Below we summarize how to ask for coverage decisions, make appeals or make a complaint if you are having trouble getting the medical care or drugs you think should be covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage, and asking us to continue covering hospital care and certain types of medical services if you think your coverage is ending too soon.

For step-by-step guidance please refer to the Evidence of Coverage (EOC) for your plan in Chapter 9, “What to do if you have a problem or complaint (coverage decisions, appeals, complaints)".

Asking for a coverage decision

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

In some cases, we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Call
Call RMHP Customer Service at 1-800-346-4643, TTY: 711
8am-8pm: 7 Days a week October-March; Monday– Friday April-September.

Write
Send us your coverage decision request in writing.

Coverage decisions for Medical Care
Rocky Mountain Health Plans Utilization Management 2775 Crossroads BLVD,
Grand Junction, CO 81506
Fax: 970-244-7769

Coverage decisions for Part D Drugs
OptumRx Prior Authorization Department
P.O. Box 25183, Santa Ana, CA 92799
Fax: 1-844-403-1028

Requesting an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we review the coverage decision we made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision. Under certain circumstances, you can request an expedited or “fast coverage decision” or fast appeal of a coverage decision.

If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an Independent Review Organization that is not connected to us. (In some situations, your case will be automatically sent to the Independent Review Organization for a Level Appeal. In other situations, you will need to ask for a Level 2 Appeal. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.

To learn more about the appeals process, refer to Chapter 9 of the Evidence of Coverage (EOC) for your plan.

Call
Call RMHP Customer Service at 1-800-346-4643, TTY: 711
8am-8pm: 7 Days a week October-March; Monday– Friday April-September.

Write
Send us your appeal in writing.

Appeals for Medical Care
Rocky Mountain Health Plans Member Appeals
P.O. Box 10600, Grand Junction, CO 81502-5600
Fax: 970-244-7819

Appeals for Part D Drugs
UnitedHealthcare Part D Appeal and Grievance Department
P.O. Box 6106, MS CA 124-0197, Cypress, CA 90630-0023
Fax: 1-866-308-6294

Making a complaint (grievance) about Medical Care or Part D Drugs

The complaint process, also known as filing a grievance, is used for certain types of problems only. This includes problems related to:

  • Quality of your medical care
  • Respecting your privacy
  • Disrespect, poor customer service, or other negative behaviors
  • Waiting times
  • Cleanliness
  • Information you get from RMHP
  • Timeliness of our actions related to coverage decisions and appeals

We must receive your complaint 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.

To learn more about the complaints process, refer to Chapter 9 Section 11 of the Evidence of Coverage (EOC) for your plan.

Call
Usually, calling Customer Service is the first step. If there is anything else you need to do, Customer Service will let you know. 1-800-346-4643, TTY: 711, 8am-8pm: 7 Days a week October-March; Monday– Friday April-September.

Write
If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.

RMHP Appeals and Grievance Department
P.O. Box 10600, Grand Junction, CO 81502-5600
Fax: 970-244-7819

Additional options if you have a Quality of Care complaint

If you have a concerns about the quality of care you received, you can make a quality of care complaint to us by using the process outlined above. When your complaint is about quality of care, you also have two extra options:

  • You can make your complaint about the quality of care you received directly to the Quality Improvement Organization (QIO) (without making the complaint to us). The 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.
  • You can make your complaint to both our plan and the QIO at the same time.

The Quality Improvement Organization (QIO) for Colorado is called KEPRO

Call
1-888-317-0891 TTY: 1-855-843-4776
9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays

Write
KEPRO
5700 Lombardo CTR DR, STE 100, Seven Hills, OH 44131

You can also tell Medicare about your complaint

To submit a complaint to Medicare, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. You can also use the Medicare Complaint Form.

Getting information about RMHP’s appeals and grievances

RMHP Members may request aggregate data regarding RMHP Medicare plan appeals and grievances.

Call
Call RMHP Customer Service at 1-800-346-4643, TTY: 711
8am-8pm: 7 Days a week October-March; Monday– Friday April-September.

Write
Rocky Mountain Health Plans Member Appeals
P.O. Box 10600, Grand Junction, CO 81502-5600