YOUR RIGHT TO MAKE COMPLAINTS
You have the right to make a complaint if you have concerns or problems related to your coverage or care. “Appeals” and “grievances” are the two different types of complaints you can make. Which one you make depends on your situation.
WHAT ARE APPEALS?
An “appeal” is the type of complaint you make when you want us to reconsider and change a decision we have made about what services or benefits are covered for you or what we will pay for a service or benefit (include Part D services and benefits). For example, if we refuse to cover or pay for services you think we should cover, you can file an appeal. If MD Care Health Plan or one of our plan providers refuses to give you a service you think should be covered, you can file an appeal. If MD Care Health Plan or one of our plan providers reduces or cuts back on services or benefits you have been receiving, you can file an appeal. If you think we are stopping your coverage of a service or benefit too soon, you can file an appeal. Except in the case of an extension of the filing time frame, you must submit your appeal within 60 calendar days from the date MD Care Health Plan denied your initial service or benefit.
HOW QUICKLY WE DECIDE ON YOUR APPEAL DEPENDS ON THE TYPE OF APPEAL:
WHAT ARE GRIEVANCES?
A “grievance” is the type of complaint you make if you have any other type of problem with MD Care Health Plan or one of our plan providers. For example, you would file a grievance if you have a problem with things such as the quality of your care, waiting times for appointments or in the waiting room, the way your doctors others behave, being able to reach someone by phone or getting the information you need, or the cleanliness or condition of the doctor’s office. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. You will be notified if MD Care takes an extension.
YOU ARE ALSO ENTITLED TO A QUICK REVIEW OF YOUR GRIEVANCE IF YOU DISAGREE WITH OUR DECISION IN THE FOLLOWING SCENARIOS:
We will quickly review your request and notify you of our decision within 24 hours of receiving your complaint.
YOU HAVE THE RIGHT TO REQUEST AN EXCEPTION TO MD Care Health Plan’s FORMULARY
You can ask MD Care Health Plan to make an exception to the coverage rules. There are several types of exceptions that you can request.
You should contact us to ask for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting such exceptions you should submit a statement from your physician.
We must respond to a request for an exception (including formulary exception, an exception from utilization management rules – such as dosage or quantity limits or step therapy requirements – or a tiering exception), and make our decision no later than 72 hours after we have received your physician’s “supporting statement,” which explains why the drug you are asking for is medically necessary.
FOR COMPLETE DETAILS ON THESE PROCESSES, PLEASE REFER TO: