Members, or their representatives, have the right to make a complaint if they have concerns or problems related to their coverage or care. “Appeals” and “grievances” are the two types of complaints members can make. All contracted providers must cooperate with the MA appeals and grievances process.

Definitions

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

Grievance: Any complaint or dispute, other than one involving an organization determination, expressing dissatisfaction with the way a Medicare health plan or delegated entity provides healthcare services, regardless of whether any remedial action can be taken. A member or their representative may make a complaint or dispute, either orally or in writing, to a Medicare health plan, provider, or facility. An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organizational determination or reconsideration, or invoked an extension.

Appeals

Expedited Appeal

An Expedited Appeal is a request to change a denial decision for urgent care. Urgent care is a request for medical care or treatment with respect to the application of the time period for making nonurgent care determinations could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment.

Inpatient services that are denied while a member is in the process of receiving the services are considered an urgent concurrent request and are therefore eligible for an Expedited Appeal. Meridian Medicare-Medicaid Plan (MMP) Provider Manual 45

Pre-Service Nonurgent Appeal

Members, their representatives, or providers, acting on behalf of a member, may request an appeal of denial in advance of the member obtaining care or services. Meridian will provide acknowledgement of the appeal within three days of receipt of the request. No provider will be involved in an appeal for which he or she made the original adverse determination. No provider will render an appeal decision who is a subordinate of the provider making the original decision to deny.

Refer to the Billing and Payment section for directions on Post-Service Appeals.

Levels of the Appeals Process

The levels of the appeals process are listed below. If an appeal is not resolved at one level, it can proceed to the next.

1. Meridian standard or expedited appeals process
2. Review by an Independent Review Entity (IRE)
3. Review by an Administrative Law Judge (ALJ)
4. Review by a Medicare Appeals Council (MAC)
5. Review by a Federal District Court Judge

If your problem is about a Medicaid service or item, you can file a Level 2 Appeal yourself with the State Hearings office. The denial letter will tell you how to do this. If your problem is about a service or item that could be covered by both Medicare and Medicaid, you will automatically get a Level 2 Appeal with the IRE. If they also deny your appeal, you can ask for another Level 2 Appeal with the State Hearings office.

Members can appeal a medical decision within 60 calendar days of receiving Meridian’s letter denying the initial request for services or payment on their own behalf. They can also designate a representative, including a relative, friend, advocate, provider, or other person, to act for them. The member and the representative must sign and date a statement giving the representative legal permission to act on the member’s behalf (“Appointment of Representative” Form CMS-1696 may be used, or a similar statement). The Member can also call the Member Services Department at the number listed in the contact information section of this manual to learn how to name an authorized representative.

Expedited or Non-urgent Pre-service appeals, and/or the representative statement may be sent to Meridian at:

Appeals for Part D (Drugs):

Meridian MMP (Medicare-Medicaid Plan) Part D Appeals
1 Campus Martius, Suite 750
Detroit, MI 48226

Fax: 1-844-328-1906
Phone: 1-855-898-1480 (TTY: 711)

Appeals for Part C (Medical and Part B Drugs):
Meridian MMP (Medicare-Medicaid Plan) Appeals
Medicare Operations 7700 Forsyth Blvd
St. Louis, MO 63105

Fax Number: 1-844-273-2671
Phone (Member Services): 1-855-580-1689

Grievances

To file a grievance, a member or their authorized representative should call the Member and Provider Services Department at 1-855-580-1689 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m., or submit in writing to:

Meridian
Grievances
Medicare Operations 7700 Forsyth Blvd
St. Louis, MO 63105

Fax Number: 1-844-273-2671

A review of the matter will be completed by our grievance coordinator. Meridian will thoroughly investigate the grievance and the member will receive a response from the grievance coordinator within 30 days.

Appeals and Grievances

A member may appeal an adverse initial decision by Meridian or a participating provider concerning authorization for or termination of coverage of a healthcare service. A member may also appeal an adverse initial decision by Meridian concerning payment for a healthcare service. A member’s appeal of a decision about authorizing healthcare or terminating coverage of a service must generally be resolved by Meridian within 15 calendar days if the member’s health condition requires. An appeal concerning payment must generally be resolved within 60 calendar days.

Participating providers must also cooperate with Meridian and members in providing necessary information to resolve the appeals within the required time frames. Participating providers must provide pertinent medical records and any other relevant information to Meridian. In some instances, participating providers must provide the records and information very quickly to allow Meridian to make an expedited decision.

If the normal time period for an appeal could result in serious harm to the member’s health or ability to function, the member or the member’s provider can request an Expedited Appeal. Such an appeal is generally resolved within 24 hours unless it is in the member’s interest to extend this time period. If a provider requests the Expedited Appeal and indicates that the normal time period for an appeal could result in serious harm to the member’s health or ability to function, we will automatically expedite the appeal.

A special type of appeal applies only to hospital discharges. Hospitals are required to notify all Meridian MMP members who are admitted to the hospital of their hospital discharge appeal rights. Hospitals must issue Important Message from Medicare About Your Rights (IM), a statutorily required notice, up to seven days before admission or within two calendar days of admission, obtain the signature of the member or of his or her representative, and provide a copy at that time. Hospitals will also deliver a copy of the signed notice as far in advance of the discharge as possible, but not less than two calendar days before discharge.

If the member thinks their hospital stay is ending too soon, the member can appeal directly and immediately to the QI Organization that is contracted with CMS. However, such an appeal must be requested no later than noon on the first working day after the day the member gets notice that Meridian’s coverage of the stay is ending. If the member misses this deadline, the member can request an Expedited Appeal from Meridian.

Another special type of appeal applies only to a member dispute regarding when coverage will end for skilled nursing facility (SNF), home health agency (HHA) or comprehensive outpatient rehabilitation facility services (CORF). Medicare regulations require the provider to deliver the standard Notice of Medicare Non-Coverage (NOMNC) to all members when covered services are ending, whether the member agrees with the plan to end services or not. Providers must distribute the NOMNC at least two days prior to enrollee’s CORF or HHA services ending and two days prior to termination of SNF services. If the member thinks his or her coverage is ending too soon, the member can appeal directly and immediately to the QI Organization. If the member gets the notice two days before coverage ends, the member must request an appeal to the QI Organization no later than noon of the day after the member gets the notice. If the member gets the notice more than two days before coverage ends, then the member must make the request no later than noon the day before the date that coverage ends. If the member misses the deadline for appealing to a QI organization, the member can request an Expedited Appeal from Meridian.

If a member has a grievance about his or her plan, a provider or any other issue, the member can call Member Services or submit a complaint in writing by mail or fax.

We will resolve the grievance as quickly as the case requires based on the member’s health status, but no later than 30 calendar days after receiving the complaint. We may extend the time frame by up to 14 days if the member requests the extension, or if we justify a need for additional information and the delay is in the member’s best interest.

Further Appeal Rights

If Meridian denies the member’s appeal in whole or in part, it will forward the appeal to an Independent Review Entity (IRE) that has a contract with the federal government and is not part of Meridian. This organization will review the appeal and, if the appeal involves authorization for healthcare services, decide within 30 days. If the appeal involves payment for care, the IRE will make the decision within 60 days. If the IRE issues an adverse decision and the amount at issue meets a specified dollar threshold, the member may appeal to an Administrative Law Judge (ALJ). If the member is not satisfied with the ALJ’s decision, the member may request review by the Medicare Appeals Council (MAC). If the MAC refuses to hear the case or issues an adverse decision, the member may be able to appeal to a Federal District Court of the United States.

Members, or their representatives, have the right to make a complaint if they have concerns or problems related to their coverage or care. “Appeals” and “grievances” are the two types of complaints members can make. All contracted providers must cooperate with the MA appeals and grievances process.

Definitions

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

Grievance: Any complaint or dispute, other than one involving an organization determination, expressing dissatisfaction with the way a Medicare health plan or delegated entity provides healthcare services, regardless of whether any remedial action can be taken. A member or their representative may make a complaint or dispute, either orally or in writing, to a Medicare health plan, provider, or facility. An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organizational determination or reconsideration, or invoked an extension.

Appeals

Expedited Appeal

An Expedited Appeal is a request to change a denial decision for urgent care. Urgent care is a request for medical care or treatment with respect to the application of the time period for making nonurgent care determinations could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment.

Inpatient services that are denied while a member is in the process of receiving the services are considered an urgent concurrent request and are therefore eligible for an Expedited Appeal. Meridian Medicare-Medicaid Plan (MMP) Provider Manual 45

Pre-Service Nonurgent Appeal

Members, their representatives, or providers, acting on behalf of a member, may request an appeal of denial in advance of the member obtaining care or services. Meridian will provide acknowledgement of the appeal within three days of receipt of the request. No provider will be involved in an appeal for which he or she made the original adverse determination. No provider will render an appeal decision who is a subordinate of the provider making the original decision to deny.

Refer to the Billing and Payment section for directions on Post-Service Appeals.

Levels of the Appeals Process

The levels of the appeals process are listed below. If an appeal is not resolved at one level, it can proceed to the next.

1. Meridian standard or expedited appeals process
2. Review by an Independent Review Entity (IRE)
3. Review by an Administrative Law Judge (ALJ)
4. Review by a Medicare Appeals Council (MAC)
5. Review by a Federal District Court Judge

If your problem is about a Medicaid service or item, you can file a Level 2 Appeal yourself with the State Hearings office. The denial letter will tell you how to do this. If your problem is about a service or item that could be covered by both Medicare and Medicaid, you will automatically get a Level 2 Appeal with the IRE. If they also deny your appeal, you can ask for another Level 2 Appeal with the State Hearings office.

Members can appeal a medical decision within 60 calendar days of receiving Meridian’s letter denying the initial request for services or payment on their own behalf. They can also designate a representative, including a relative, friend, advocate, provider, or other person, to act for them. The member and the representative must sign and date a statement giving the representative legal permission to act on the member’s behalf (“Appointment of Representative” Form CMS-1696 may be used, or a similar statement). The Member can also call the Member Services Department at the number listed in the contact information section of this manual to learn how to name an authorized representative.

Expedited or Non-urgent Pre-service appeals, and/or the representative statement may be sent to Meridian at:

Appeals for Part D (Drugs):

Meridian MMP (Medicare-Medicaid Plan) Part D Appeals
1 Campus Martius, Suite 750
Detroit, MI 48226

Fax: 1-844-328-1906
Phone: 1-855-898-1480 (TTY: 711)

Appeals for Part C (Medical and Part B Drugs):
Meridian MMP (Medicare-Medicaid Plan) Appeals
Medicare Operations 7700 Forsyth Blvd
St. Louis, MO 63105

Fax Number: 1-844-273-2671
Phone (Member Services): 1-855-580-1689

Grievances

To file a grievance, a member or their authorized representative should call the Member and Provider Services Department at 1-855-580-1689 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m., or submit in writing to:

Meridian
Grievances
Medicare Operations 7700 Forsyth Blvd
St. Louis, MO 63105

Fax Number: 1-844-273-2671

A review of the matter will be completed by our grievance coordinator. Meridian will thoroughly investigate the grievance and the member will receive a response from the grievance coordinator within 30 days.

Appeals and Grievances

A member may appeal an adverse initial decision by Meridian or a participating provider concerning authorization for or termination of coverage of a healthcare service. A member may also appeal an adverse initial decision by Meridian concerning payment for a healthcare service. A member’s appeal of a decision about authorizing healthcare or terminating coverage of a service must generally be resolved by Meridian within 15 calendar days if the member’s health condition requires. An appeal concerning payment must generally be resolved within 60 calendar days.

Participating providers must also cooperate with Meridian and members in providing necessary information to resolve the appeals within the required time frames. Participating providers must provide pertinent medical records and any other relevant information to Meridian. In some instances, participating providers must provide the records and information very quickly to allow Meridian to make an expedited decision.

If the normal time period for an appeal could result in serious harm to the member’s health or ability to function, the member or the member’s provider can request an Expedited Appeal. Such an appeal is generally resolved within 24 hours unless it is in the member’s interest to extend this time period. If a provider requests the Expedited Appeal and indicates that the normal time period for an appeal could result in serious harm to the member’s health or ability to function, we will automatically expedite the appeal.

A special type of appeal applies only to hospital discharges. Hospitals are required to notify all Meridian MMP members who are admitted to the hospital of their hospital discharge appeal rights. Hospitals must issue Important Message from Medicare About Your Rights (IM), a statutorily required notice, up to seven days before admission or within two calendar days of admission, obtain the signature of the member or of his or her representative, and provide a copy at that time. Hospitals will also deliver a copy of the signed notice as far in advance of the discharge as possible, but not less than two calendar days before discharge.

If the member thinks their hospital stay is ending too soon, the member can appeal directly and immediately to the QI Organization that is contracted with CMS. However, such an appeal must be requested no later than noon on the first working day after the day the member gets notice that Meridian’s coverage of the stay is ending. If the member misses this deadline, the member can request an Expedited Appeal from Meridian.

Another special type of appeal applies only to a member dispute regarding when coverage will end for skilled nursing facility (SNF), home health agency (HHA) or comprehensive outpatient rehabilitation facility services (CORF). Medicare regulations require the provider to deliver the standard Notice of Medicare Non-Coverage (NOMNC) to all members when covered services are ending, whether the member agrees with the plan to end services or not. Providers must distribute the NOMNC at least two days prior to enrollee’s CORF or HHA services ending and two days prior to termination of SNF services. If the member thinks his or her coverage is ending too soon, the member can appeal directly and immediately to the QI Organization. If the member gets the notice two days before coverage ends, the member must request an appeal to the QI Organization no later than noon of the day after the member gets the notice. If the member gets the notice more than two days before coverage ends, then the member must make the request no later than noon the day before the date that coverage ends. If the member misses the deadline for appealing to a QI organization, the member can request an Expedited Appeal from Meridian.

If a member has a grievance about his or her plan, a provider or any other issue, the member can call Member Services or submit a complaint in writing by mail or fax.

We will resolve the grievance as quickly as the case requires based on the member’s health status, but no later than 30 calendar days after receiving the complaint. We may extend the time frame by up to 14 days if the member requests the extension, or if we justify a need for additional information and the delay is in the member’s best interest.

Further Appeal Rights

If Meridian denies the member’s appeal in whole or in part, it will forward the appeal to an Independent Review Entity (IRE) that has a contract with the federal government and is not part of Meridian. This organization will review the appeal and, if the appeal involves authorization for healthcare services, decide within 30 days. If the appeal involves payment for care, the IRE will make the decision within 60 days. If the IRE issues an adverse decision and the amount at issue meets a specified dollar threshold, the member may appeal to an Administrative Law Judge (ALJ). If the member is not satisfied with the ALJ’s decision, the member may request review by the Medicare Appeals Council (MAC). If the MAC refuses to hear the case or issues an adverse decision, the member may be able to appeal to a Federal District Court of the United States.