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

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.

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: 1.833.522.3767 (TTY: 711)
Fax: 1.213.438.5712
Mail: L.A. Care Medicare Plus
Attn: Member Services Department
1055 West 7th Street, 10th Floor
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.

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 Hearing.

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: 1.833.522.3767 (TTY: 711)
Fax: 1.213.438.5712
Mail: L.A. Care Medicare Plus
Attn: Appeals and Grievance Unit
1055 W. 7th Street, 10th Floor
Los Angeles, CA 90017

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 download it from the Medicare 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.

You must ask for an appeal within 60 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.

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.

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.

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.

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.

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.

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

You can request a State 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 Medicare Plus, you have the right to ask for a State Hearing.

In most cases you have 120 days to ask for a State Hearing after the “Notice of Appeal Resolution (NAR)” 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 Hearing:

1. You may complete the "Request for State Hearing" on the back of the Notice of Appeal Resolution (NAR). 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 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 Medicare Plus 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

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.

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 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.

If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision. If the State 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 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 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 your Level 2 Appeal was a State 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 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 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.

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 Hearing. You must file a request for a State Hearing within 90 days after the date of the county’s action or inaction. 

There are two ways to ask for a State 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).
 

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.

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.