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 1-833-522-3767 (TTY: 711).
Call the Ombuds Program for free help at 1-855-501-3077. The Ombuds Program helps people enrolled in D-SNP with service or billing problems.
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. 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.