Part C: Coverage Decision and Appeals

This section is about what to do if you have problems with your benefits for your medical, behavioral health, and long-term services and supports (LTSS). You can also use this section for problems with drugs that are not covered by Part D. Drugs in the List of Covered Drugs with a DP are not covered by Part D.

How to ask for coverage decision to get medical, behavioral health, or certain long-term services and supports (MSSP, CBAS, or NF services) 

To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a 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 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 an expedited coverage decision for Part C services?
Yes. If you need a response faster because of your health, you should ask us to make an “expedited coverage decision 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 expedited coverage decision:

• If you request an expedited 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 expedited coverage decision:
You must meet the following two requirements to get an expedited coverage decision:

• You can get an expedited coverage decision only if you are asking for coverage for care or an item you have not yet received. (You cannot get an expedited coverage decision coverage decision if your request is about payment for care or an item you have already received.)
• You can get an expedited 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 an expedited coverage decision, we will automatically give you one.
• If you ask for an expedited coverage decision, without your doctor’s support, we will decide if you get an expedited coverage decision.
• If we decide that your health does not meet the requirements for an expedited 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 expedited coverage decision, we will automatically give a an expedited coverage decision. 
• The letter will also tell how you can file an “expedited appeal” about our decision to give you a an expedited coverage decision instead of the expedited 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 an expedited 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. If you or your doctor or other provider disagrees with our decision, you can appeal. In most cases, you must start your appeal at Level 1.

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. 

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. Please see below for more information.

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 “expedited appeal.”
• If you are asking for a standard appeal or expedited appeal, make your appeal in writing or call IEHP DualChoice Member Services:  
IEHP DualChoice
P.O. Box 1800
Rancho Cucamonga, CA 91729-1800 
• 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. 

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 an “expedited appeal” about our decision to take extra days. When you file an expedited appeal, we will give you an answer to your appeal within 72 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 an expedited appeal?
If you ask for an expedited 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. 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?

During the appeal process you can have your benefits continued if requested within ten (10) days of IEHP mailing the notice of action or before the intended effective date of the proposed action. The appeal must involve the termination, suspension, or reduction of a previously authorized course of treatment ordered by an authorized Provider. In addition, the original period covered by the original authorization must not have expired and you requested the extension of benefits. If the final resolution of the appeal upholds IEHP’s action, IEHP’s Compliance Department may recover the cost of the Medi-Cal and/or Medicare services furnished to the enrollee while the appeal is pending, to the extent that they were furnished.

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. See page 141 for information about our Level 1 appeal process. 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:
• Fill out the Independent Medical Review/Complaint Form available at: http://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForm.aspx. Or call the DMHC Help Center at 1-888-466-2219. TDD users should call 1-877-688-9891.
• If you have them, 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. 
• Fill out the Authorized Assistant Form if someone is helping you with your IMR. You can get the form at http://www.dmhc.ca.gov/Portals/0/FileAComplaint/IMRForms/imrAuthorizationForm.pdf. Or call the DMHC Help Center at 1-888-466-2219. TDD users should call 1-877-688-9891.
• Mail or fax your forms and any attachments to: 
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 may also make a toll-free call to request a State Hearing for Medi-Cal covered services and items (including IHSS). Call the California Department of Social Services at 1-800-952-5253. TDD users should call 1-800-952-8349. You must ask for an appeal within 120 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.

The State will hold a hearing.  You may attend the hearing in person or by phone.  You’ll be asked to tell the State why you disagree with our decision.  You can ask a friend, relative, advocate, provider, or lawyer to help you.  You’ll get a written decision that will explain if you have additional appeal rights. 

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 before the date that your benefits are changed or taken away in order to get the same benefits until your hearing.

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.

Appeal a County’s decision regarding authorized hours for IHSS benefits
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. The 90 days start the day after the date your notice. If we’re stopping or reducing a service, you can keep getting the service while your case is being reviewed. If you want the service to continue, you must ask for an appeal or a State Hearing within 10 days of the date of this notice or before the service is stopped or reduced, whichever is later. Your provider must agree that you should continue getting the service.

Payment Problems

If you want to ask us for payment for medical care, start by reading Chapter 7 of this booklet: Asking us to pay our share of a bill you have gotten for covered services or drugs. Chapter 7 describes the situations in which you may need to ask for reimbursement or to pay a bill you have received from a provider. It also tells how to send us the paperwork that asks us for payment. 

How do I ask the plan to pay me back for the plan’s share of medical services or items I paid for?

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 an 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 our share of the cost of 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 an 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. 

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 expedited 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 5, 2017
H5355_CMC_18_668327 Pending