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MA PAP405

Medicare Advantage Member Appeals Process


Provider Administrative Policy

Section
Member Rights and Responsibilities
Policy Date
July 2007
Status/Date
Revised/April 2010

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Medicare Advantage Member Appeals Process

Medicare Advantage plans must comply with specific requirements to notify our members in writing when we deny a payment or request for service.

Blue Cross of Idaho is responsible for providing our members with coverage information. Please refer our members to Blue Cross of Idaho Medicare Advantage Customer Service when they have questions about their coverage (see MA PAP102).

Medicare Advantage plan members have the right to appeal decisions about payment for services and failure to arrange or continue to arrange for services they believe are covered (including non-Medicare covered benefits) under Medicare Advantage. The Medicare Advantage member appeals process includes appeals for prescription drugs, Part C medical care or services and costs. 

Pre-Service Appeals:
A provider may expedite a reconsideration request (appeal) on behalf of a member if they feel the standard reconsideration timeframe adversely affects the member's life, health or ability to regain maximum function. Upon providing notice to the member, a treating physician may request a standard service reconsideration (appeal) on that member's behalf. Providers do not need to obtain an appointment of representation document from the member, nor are they required to execute a waiver of enrollee liability. 

Examples of commonly appealed coverage decisions include:

  • Services not yet received, but which the member feels Medicare Advantage is responsible for paying or for arranging.
  • Discontinuation of services the member believes to be medically necessary.

Providers may submit a letter of support for member initiated standard appeals.

For complaints that do not involve coverage decisions, members should follow the Medicare Advantage grievance procedure. Medicare Advantage has both a standard determination and appeals procedure and an expedited determination and appeals procedure. Members can find complete information on appeals and grievance procedures in their Evidence of Coverage (EOC). When members have questions about which complaint process to use, refer them to Medicare Advantage Customer Service. Providers can request a copy of the plan's EOC by calling Medicare Advantage Customer Service (see MA PAP102).

Providers agree to cooperate fully with identification, investigation and resolution of any member complaint under the grievance and appeals procedures as set forth in the EOC. Providers also agree to cooperate fully and agree to accept as final and binding, decisions resulting from the reconsideration and appeals process. The appeals process does not apply to a doctor's determination of an appropriate medical treatment plan for their patient. If a patient and doctor discuss a service the doctor does not believe is medically indicated, please document the discussion in the patient's medical record.

Should any dispute arise later, documentation in the member's medical record will assist in an appropriate resolution. If a member requests a service that their doctor does not believe is medically indicated, contact the Medicare Advantage care coordination team (see MA PAP102). They will issue the appropriate documentation for denied services as required by the Centers for Medicare and Medicaid Services.


Policy History

Date Action Reason
April 2010 Revised Pre-appeal language added
March 2009 Revised Part C language added

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