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Appeals Process

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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.

You must ask for an appeal within 90 calendar days for medical services and for drug coverage within 60 calendar days from the date on the letter we sent to tell you our decision. If you miss the deadline for a good reason, you may still appeal. You will receive a letter from us within 5 calendar days of receiving your appeal letting you know that we received it. See below for instructions on how to start an appeal.

Here is the step-by-step process for Level 1 Appeal

Step 1

You contact us and make your Level 1 Appeal. If your health requires a quick response, you must ask for a 'fast appeal'.

To start your appeal, you (or your representative or your doctor or other prescriber) must contact us.

For expedited requests ('fast appeal'): Please call or fax using the contact numbers above

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 Fair Hearing or, in special cases, an Independent Medical Review.

Step 2

We consider your appeal and we give you our answer

When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We may contact you or your doctor or other prescriber to get more information.

Timeframe

Fast Appeals

For Medical Coverage 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 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. (See below for Level 2 Appeals Process)
  • 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.

For Drug Coverage Fast Appeal

If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it.

  • If we do not give you an answer within 72 hours, we will send your request on to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review our decision.
  • If our answer is Yes to part or all of what you asked for, we must give 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 that explains why we said No.

Standard Appeals

For Medical Coverage Standard Appeal

For standard appeals, we will give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. We will give your our answer within 60 calendar days, if your appeal is for payment for services you have already received. 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. For more information about the Level 2 Appeal process, please read level 2 process.
  • 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.

For Drug Coverage Standard Appeal

For standard appeals, we will give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so.

  • If we do not give you a decision within 7 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization.

If our answer is Yes to part or all of what you requested, we will do the following:

  • If the request is for prescription coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal. Or,
  • If the request is to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.

Step 3

If our plan says No to part or all of your appeal

For Medical Coverage

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.

For Drug Coverage

If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Entity will review our decision.


Here is the step-by-step process for Level 2 Appeal

Step 1

The Independent Review Organization reviews your appeal.

For Medical Coverage

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

Medicare Level 2 Appeals:

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.

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.

Medi-Cal Level 2 Appeals:

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

  1. Independent Medical Review (IMR)
    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.
    To request an IMR:
    • Fill out the Complaint/Independent Medical Review (IMR) Application Form available at www.dmhc.ca.gov/dmhc_consumer/pc/pc_forms.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 www.dmhc.ca.gov/dmhc_consumer/pc/pc_forms.aspx or by calling 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
  2. State Fair Hearing
    You can request a State Fair Hearing at any time for Medi-Cal covered services and items (including IHSS). 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, you have the right to ask for a State Fair Hearing.

    In most cases you have 90 days to ask for a State Fair Hearing after the “Your Hearing Rights” 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 Fair Hearing:

  1. You may complete the "Request for State Fair 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:
  2. You may make a toll-free call to request a State Fair 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.

For Drug Coverage

If you want the Independent Review Entity to review your case, your appeal request must be in writing. The letter we send about our decision in the Level 1 Appeal will explain how to request the Level 2 Appeal.

Fast Appeal

Standard Appeal

Step 2

The Independent Review Organization gives you their answer.

If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision.

If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining the decision made by the doctors who reviewed your case.

If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision.

Step 3

If your case meets the requirements, you choose whether you want to take your appeal further (Level 3).

For Drug Coverage

What if the Independent Review Entity says No to your Level 2 Appeal?

For appeals for Hospital discharge dates, covering other services like skilled nursing, outpatient services and home health care, please refer to Evidence of coverage Chapter 9 sections 7-10 or call Care1st Member Services.

EXTRA HELP

If you need further help, call the Cal MediConnect Ombudsman at 1-855-501-3077.

You can also call the HMO Help Center at 1-888-466-2219. They can help you file a complaint or ask for an Independent Medical Review.





You may ask to obtain the aggregate numbers of the plan's grievances, appeals, and exceptions . Please contact Member Services at 1-855-905-3825 (TTY: 711)