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Grievance and appeals

SSM Health Employee health plan

Complaint

A complaint is any expression of dissatisfaction expressed to Us by the member, or a member's authorized representative, about Us or Our Providers with whom We have a direct or indirect contract. We take all member complaints seriously and are committed to responding to them in an appropriate and timely manner.

lf You have a complaint, please contact member services at 877-274-4693. We will document and investigate your complaint and notify You of the outcome. lf Your complaint is not resolved to Your satisfaction You, Your Health Care Provider, or Your Authorized Representative may file a grievance.

Grievance

A grievance is any written complaint submitted by or on behalf of a member expressing dissatisfaction with Us, including:

  • the way we provide services or process claims;
  • a decision to change or rescind a policy;
  • an Adverse Determination made by Utilization Management;
  • reimbursement for health care services; or
  • availability, delivery or quality of health care services.

An Adverse Determination is a denial, reduction, or termination of benefits because the care does not meet Our definition of medical necessity, appropriateness, health care setting, level of care or effectiveness.

To file a grievance, You or Your Authorized Representative must send grievances to Us in writing within 180 days of the original Adverse Determination at the following address:

Medica
Attention: Grievance and Appeal Department
P.O. Box 56099
Madison, WI 53705

We will not charge You for filing a grievance with Us. You will have continued coverage under this insurance policy pending the outcome of an internal appeal. This applies for covered services only. When We receive Your grievance, Our Grievance and Appeal Department will send you an acknowledgement letter within five business days. Our acknowledgment letter will advise you of:

  • Your right to submit written comments, documents or other information regarding your grievance;
  • Your right to be assisted or represented by another person of your choosing;
  • Your right to appear before the Grievance and Appeal Committee; and
  • The date and time of the next scheduled Grievance and Appeal Committee meeting.

If You choose to meet with the Grievance and Appeal Committee You may do so either in person or over the phone via teleconference. As described in the acknowledgement letter, You must call and schedule a meeting time.

The Grievance and Appeal Committee will consist of:

  • Individuals who were not involved in the initial decision review and not a subordinate of the individuals who were involved in the initial decision review;
  • Other enrollees; and/or
  • In cases of an adverse determination, involving medical judgment, a majority of persons that are health care professional of a same and similar specialty.

Your grievance will be documented and investigated. So that You have time to respond prior to Our grievance decision, We will automatically send You the following information:

  • Any new or additional evidence We consider, rely upon, or generate in the course of considering your grievance; or
  • Any new or additional rationale We use to make Our decision.

At any time if You wish to receive a free copy of any other documents relevant to the outcome of your grievance, send a written request to the address listed above. All grievances will be resolved within 30 calendar days from the day We receive Your request. You have the right to bring a civil action under Section 502 of ERISA following an Adverse Benefit Determination on review (Our grievance decision).

Expedited Grievance

lf We decide Your grievance is urgent according to Our criteria, We will resolve Your grievance within 72 hours of the time when We receive it. Our criteria are based on the expedited grievance provisions of applicable law.

We will automatically treat your grievance as expedited if:

  • Your concerns are related to a facility admission or concurrent review of a continued facility stay;
  • Our Medical Director decides your life, health, or ability to regain maximum function could be jeopardized by the standard review time frame;
  • Your Health Care Provider notifies Us that you would be subject to severe pain that cannot be adequately managed without the services you requested; or
  • Your Health Care Provider notifies Us that he or she has decided you need care urgently.

You, Your Authorized Representative or Your Health Care Provider may request an expedited grievance either orally at 608-828-1991, by fax at 608-252-0812, or in writing at Medica, Attention: Grievance and Appeal Department, P.O. Box 56099, Madison, WI 53705. You can make this request in your initial grievance or in a separate communication.

lf You are eligible for an expedited internal grievance and also for external review, You can request that Your internal and external reviews happen at the same time. You have the right to bring a civil action under Section 502 of ERISA following an Adverse Benefit Determination on review (Our grievance decision).

Independent External Review

You may also be entitled to an independent external review (IER). You can ask for an external review if We denied your grievance and it involves care that We have determined does not meet the Policy requirements for reasons involving medical judgement. Those reasons include, but are not limited to:

  • Medical Necessity;
  • Appropriateness;
  • Health care setting;
  • Level of care; or
  • Effectiveness of a covered benefit.

You can also request an external review if Your requested services are considered Experimental or Investigational or if We have rescinded your Policy, whether You or a Qualified Dependent is entitled to a reasonable alternative standard for a reward under a wellness program, or whether We are complying with the non-quantitative treatment limitation provisions of mental health parity requirements.

You must exhaust Our internal review process before You can request an external review
unless:

  • We fail to comply with internal claims and appeals requirements;
  • You request an expedited external review when you request an expedited internal review; or
  • We grant your request to bypass Our internal review process.

If You or Your Authorized Representative wishes to request an external review, You or Your Authorized Representative must submit Your request within four months of the date We decided your grievance. There are two categories of external review, standard and expedited. Most requests for external review will follow the standard timeline; however in some cases you may ask for an expedited (faster) review.

Standard External

You may request a standard external review in one of the following ways:

  • By directly submitting the request online at externalappeal.cms.gov;
  • By mailing the request to the independent review organization (IRO) at the following address: 
    • MAXIMUS Federal Services
      3750 Monroe Avenue, Suite 705
      Pittsford, NY 14534
  • By faxing the request to 888-866-6190.

If You choose to mail or fax your request, print and fill out the online form. You can get the online form at externalappeal.cms.gov or by calling member services at 877-274-4693 (TTY: 711). Please note additional documentation may also be provided, such as:

  • Documents to support the claim, such as letters from your Health Care Provider, reports, bills, medical records, explanation of benefits (EOB) forms (optional);
  • Letters sent to your health insurance plan about the denied claim (optional); and
  • Letters received from the health insurance plan (optional).
     

The IRO will notify You and Us of its decision no later than 45 days after it receives Your request for external review.

A decision made by the IRO is binding for both You (the Member) and Us. You are not responsible for the costs associated with the IER.

Expedited External Review

In some cases You may ask for an expedited (faster than usual) external review. You may request an expedited external review when:

  • You have asked for an expedited grievance and want an expedited external review concurrently (at the same time) and the time frame for an expedited grievance (72 hours) would place your life, health, or ability to regain maximum function in danger; or
  • You have completed the grievance process described above and the decision was not in your favor, and:
    • The time frame to do a standard external review (45 days) would place your life, health or ability to regain maximum function in danger; or
    • The decision is about admission, care availability, continued stay, or emergency health care services where the person has not been discharged from the facility.

You may request an expedited external review by following the process described above for standard external reviews, or by calling the IRO at 888-866-6205. The 72 hour time frame for an expedited review request begins when the phone call ends.

The IRO will notify You and Us of its decision as soon as possible, but no later than 72 hours after it receives Your request for external review. The IRO may call You with its decision, but it must also mail You a written version of the decision within 48 hours of calling You.

A decision made by the IRO is binding for both Us and the Member. You are not responsible for the costs associated with the IER.

U.S. Department of Labor, Employee Benefits Security Administrator

You may resolve your problem by taking the steps outlined above. You may also contact the Employee Benefits Security Administrator of the U.S. Department of Labor and file a complaint.

You may file a complaint online at:

https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa

You may also request a complaint form by calling 866-444-3272 or by writing to:

U.S. Department of Labor
Employee Benefits Security Administration
200 Constitution Ave., NW
Washington, DC 20210

Contact

At times you may have questions and concerns about benefits, claims or services you receive from Medica. Sharing your concerns will help Us to identify our strengths and weaknesses.

When a question or concern arises, we encourage you to reach out to member services at 877-274-4693. Our customer care specialists will make every effort to resolve your concern promptly and completely. Your input matters, and we encourage you to call with any concerns you may have regarding your health care.