What is an appeal?
An appeal is a formal request made in writing to the plan requesting a review of an adverse benefit determination.
Beneficiaries or appointed representatives can file an expedited/fast appeal at any time when the beneficiary or his/her physician believes that waiting for a decision under the standard time frame could place the beneficiary’s life, health, or ability to regain maximum function in serious jeopardy.
When can you file an appeal?
You can file an appeal:
- When you get a denial for an expedited (time-sensitive) medical and (or) prescription drug coverage.
- When you disagree with what the health plan pays or what you must pay out of pocket for your medical or prescription service.
- When you are refused service by the health plan, your doctor or hospital.
- When the health plan reduces or stops your medical or prescription benefit.
- When you want to ask us to cover a drug that is not on our drug list.
What is a grievance?
A grievance is any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which the health plan, prescription drug plan, or delegated entity provides health care services, regardless of whether any remedial action can be taken.
When can you file a grievance?
You can file a grievance:
- When you are dissatisfied with a change in premiums or cost-sharing arrangements from one contract year to the next.
- When you have difficulty getting through on the telephone to speak to a representative.
- Due to poor quality of care services from a provider.
- Due to interpersonal aspects of care such as rudeness by a provider or staff member.
- When you express general dissatisfaction about a copayment, coinsurance, and/or deductible amount.
A beneficiary or their representative may make the complaint or dispute in writing to the health plan. The table below lists all appeals and grievance submissions and the resolution timeframes.
All appeals and grievances must be submitted to:
|US Family Health Plan|
|Type of inquiry||Timeline for submission||Applies to||Appeal Review||Standard Timeframe||Expedited Turnaround Time|
|Payment||90 calendar days from denial date||Denied payment for a service already received||US Family Health Plan||Within 90 calendar days||Not available|
|Service||Three calendar days from denial date||Denied request for a health service not already received||US Family Health Plan||Within calendar 30 days||Within three business days|
|Grievance||Any time||Member dissatisfaction||US Family Health Plan||Within 30 calendar days||Within three business days|