Part C: Coverage Decision and Appeals

This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. It also includes problems with payment. You are not responsible for Medicare costs except for Part D copays.

How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (MSSP, CBAS, or NF services)
To ask for an coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision.

  • You can call us at: 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays.  TTY: 1-800-718-4347.  
  • You can fax us at: 1-909-890-5877  
  • You can to write us at: IEHP DualChoice, P.O. Box 1800, Rancho Cucamonga, CA 91729-1800.

How long does it take to get a standard coverage decision coverage decision for Part C services?
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 calendar more days.

Can I get a coverage decision faster for Part C services?
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 coverage decision coverage 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 an fast coverage decision coverage decision:

  • If you request a fast coverage decision coverage decision, start by calling or faxing our plan to ask us to cover the care you want.  
  • You can call IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347 or fax us at 1-909-890-5877.
  • You can also have your doctor or your representative call us.

Here are the rules for asking for an fast coverage decision coverage decision:

You must meet the following two requirements to get an fast coverage decision coverage decision:
  • You can get a fast coverage decision 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 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 an 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 appeal” about our decision to give you a fast coverage decision instead of the fast coverage decision you requested.

If the coverage decision is Yes, when will I get the service or item?
You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period.

If the coverage decision is No, how will I find out?
If the answer is No, we will send you a letter telling you our reasons for saying No.

  • If we say no, you have the right to ask us to reconsider – and change – this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage.
  • If you decide to make an appeal, it means you are going on to Level 1 of the appeals process.

Appeals

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.

In most cases, you must start your appeal at Level 1. If you do not want to first appeal to the plan for a Medi-Cal service, in special cases you can ask for an Independent Medical Review. If you need help during the appeals process, you can call the Cal MediConnect Ombuds Program at  1-855-501-3077. The Cal MediConnect Ombuds Program is not connected with us or with any insurance company or health plan.

What is a Level 1 Appeal for Part C services?
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.

Can someone else make the appeal for me for Part C services?
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.

  • 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.

How do I make a Level 1 Appeal for Part C services?
To start your appeal, you, your doctor or other provider, or your representative must contact us. You can call IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347. For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook.

  • You can ask us for a “standard appeal” or an “fast appeal.”
  • If you are asking for a standard appeal or fast appeal, make your appeal in writing:

IEHP DualChoice
P.O. Box 1800
Rancho Cucamonga, CA 91729-1800

Fax: (909) 890-5748

  • You may also ask for an appeal by calling IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347.

We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it.

How much time do I have to make an appeal for Part C services?
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.

Can I get a copy of my case file?
Yes. Ask us for a copy.

Can my doctor give you more information about my appeal for Part C services?
Yes, you and your doctor may give us more information to support your appeal.

How will the plan make the appeal decision?
We take a careful look at all of the information about your request for coverage of medical care. Then, we check to see if we were following all the rules when we said No to your request. The reviewer will be someone who did not make the original decision. If we need more information, we may ask you or your doctor for it.

When will I hear about a “standard” appeal decision for Part C services?
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 appeal 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. Please see below for more information. 

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. Please see below for more information.

What happens if I ask for a fast appeal?
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 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 appeal within 24 hours.
  • 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. Please see below for more information.

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. Please see below for more information.

Will my benefits continue during Level 1 appeals?
If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. If you disagree with the action, you can file a Level 1 Appeal and ask that we continue your benefits for the service or item. You must make the request on or before the later of the following in order to continue your benefits:

  • Within 10 days of the mailing date of our notice of action; or
  • The intended effective date of the action.

If you meet this deadline, you can keep getting the disputed service or item while your appeal is processing.

Level 2 Appeal

If the plan says No at Level 1, what happens next?

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.

What is a Level 2 Appeal?

A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan.  

My problem is about a Medi-Cal service or item. How can I make a Level 2 Appeal?
There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing.

1)    Independent Medical Review

You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). An IMR is available for any Medi-Cal covered service or item that is medical in nature. 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 can apply for an IMR if our plan:

  • Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary.
  • Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition.
  • Will not pay for emergency or urgent Medi-Cal services that you already received.
  • Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal.

You can ask for an IMR if you have also asked for a State Hearing, but not if you have already had a State Hearing, on the same issue.

In most cases, you must file an appeal with us before requesting an IMR. If you disagree with our decision, you can ask the DMHC Help Center for an IMR.

  • If your treatment was denied because it was experimental or investigational, you do not have to take part in our appeal process before you apply for an IMR.
  • If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHC’s attention. The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases.

You must apply for an IMR within 6 months after we send you a written decision about your appeal. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time.

To ask for an IMR:

Help Center

Department of Managed Health Care

980 Ninth Street, Suite 500

Sacramento, CA 95814-2725

FAX: 916-255-5241

For non-urgent cases involving Medi-Cal services (not including IHSS), you will get an IMR decision from the DMHC within 30 days of receipt of your application and supporting documents. For urgent cases that involve an immediate or serious risk to your health, you will get an IMR decision within 3 to 7 days

If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. 

If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process.

2)    State Hearing

You can ask for a State Hearing for Medi-Cal covered services and items. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, 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 “Your Hearing Rights” notice is mailed to you. 

There are two ways to ask for a State Hearing:

  1. You may complete the "Request for State Hearing" on the back of the notice of action. 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 916-651-5210 or 916-651-2789.

2. You can call the California Department of Social Services at 1-800-952-5253. TDD users should call 1-800-952-8349. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy.

Will my benefits continue during Level 2 appeals?
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 Fair Hearing, your Medi-Cal benefits for that service or item will continue until a hearing decision is made. You must ask for a hearing on or before the later of the following in order to continue your benefits:

  • Within 10 days of the mailing date of our notice to you that the adverse benefit determination (Level 1 appeal decision) has been upheld; or
  • The intended effective date of the action.

If you meet this deadline, you can keep getting the disputed service or item until the hearing decision is made.

How will I find out about the decision?
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 the decision is No for all or part of what I asked for, can I make another 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.

Payment Problems

We do not allow our network providers to bill you for covered services and items. This is true even if we pay the provider less than the provider charges for a covered service or item. You are never required to pay the balance of any bill. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. If you get a bill that is more than your copay for covered services and items, send the bill to us. You should not pay the bill yourself. We will contact the provider directly and take care of the problem.

How do I ask the plan to pay me back for the plan’s share of medical services or items I paid for?
Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items.

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 service or item you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of the service or item 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 service or item 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.

What if the plan says they will not pay?
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 an 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 (see above).

IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.

Information on this page is current as of September 30, 2017. 

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