DEFINITIONS - Complaint, Grievance, Appeal, reconsideration , Quality improvment organization (QIO)

Complaint:
Any expression of dissatisfaction by a Member, including dissatisfaction with the administration, claims practices, or provision of services, which related to the quality of care provided by a provider pursuant to the organization’s contract and which is submitted to the organization or to a state agency.  

Grievance:
Any complaint or dispute, other than one involving an organization/coverage determination, expressing dissatisfaction  with  the  manner  in  which  CarePlus  or  delegated  entity  provides  health  care  services, regardless of whether any remedial action can be taken.  An enrollee or their representative may make the complaint or dispute, either orally or in writing, to CarePlus, provider or facility.  An expedited grievance may also include a complaint that CarePlus refused to expedite an organization/coverage determination, reconsideration or redetermination or invoked an extension to an organization/coverage determination or reconsideration/redetermination time frame.

In  addition,  grievances  may  include  complaints  regarding  the  timeliness,  appropriateness,  access  to, and/or  setting  of  a  provided  health  service,  procedure,  or  item.    Grievance  issues  may  also  include complaints  that a  covered health service procedure or item  during  a course of treatment  did not  meet accepted standards for delivery of health care.

Quality Improvement Organization (QIO):
Organizations comprised of practicing doctors and other health care experts under contract to the Federal government to monitor and improve the care given to Medicare enrollees.  QIOs review complaints raised by  enrollees  about  the  quality  of  care  provided  by  physicians,  inpatient  hospitals,  hospital  outpatient department, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare health plans,  and  ambulatory  surgical  centers.  The  QIOs  also  review  continued  stay  denials  for  enrollees receiving care in acute inpatient hospital facilities as well as coverage terminations in SNFs, HHAs, and CORFs.

Initial determination (Organization Determination):
A member must ask for a standard organization determination by making a request with the Plan, or if applicable, the entity responsible for making the determination (as directed by the Plan), in accordance with the following: the request may be made orally or in writing, except where the request is for payment.

An  organization  determination  is  any  determination  made  by  the  Plan  with  respect  to  any  of  the following:

** Payment for temporarily out of the area renal services, emergency services, post-stabilization care or urgently needed services.
** Payment for any other health services furnished by a provider or supplier other than CarePlus, that the Member or former Member believes are covered under Medicare; or if not covered under Medicare, should have been furnished, arranged for, or reimbursed by CarePlus.
** A refusal by CarePlus to provide or pay for services in whole or in part, including the type or level of services that the Member believes should be furnished or arranged for by CarePlus.
** Reduction, or premature discontinuation, of a previously authorized ongoing course of treatment.
** Failure of CarePlus to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee.

Appeal:  
Any of the procedures that deal with the review of adverse organization determinations on the health care services an enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the member), or any amounts the enrollee must pay for a service as defined in 42 CFR 422.566 (b).  These procedures include reconsideration by the Health plan and if necessary, an independent review entity, hearings before Administrative  Law  Judges  (ALJ’s),  review  by  the  Medicare  Appeals  Council  (MAC),  and  judicial review.

Reconsideration:   

A member’s first step in the appeals process after an adverse organization determination; the health plan or independent review entity may re-evaluate an adverse organization determination, the findings upon which it was based, and any other evidence submitted or obtained.

What is Expedited Appeals Expedited Appeals

An expedited appeal is a review of a time-sensitive adverse organization determination or coverage determination that a member believes that he/she is entitled to receive, including:

** Any delay in provding, arranging for, or approving health care services/medications that would adversely affect the health of the member

** Reduction or stoppage of treatment or services that would adversely affect the member’s health

Note: Time-sensitive is defined as a situation in which applying the standard decision time frame could seriously jeopardize a member’s life, health, or ability to regain maximum function.

Members, their representatives, or any treating or prescribing physician (regardless of whether the provider is affiliated with Tufts Medicare Preferred HMO) can request an expedited appeal. Verbal and written requests for expedited appeals are accepted. If the request meets the necessary time-sensitive criteria, a decision will be made within 72-hours of receipt of the request, unless an extension is needed. Extensions of up to 14 calendar days can be granted if in the best interest of the member.

Note: Extensions are not allowed for expedited Part D appeals.