Peoples Health Group Medicare (HMO-POS)
Plan Details: Appeals and Grievances
Appeals and Grievances
This page provides general information about appeals. The following topics are included:
» What are appeals?
» How do you ask for an appeal?
» Important links, documents and forms
Appeals for Medical Care
» What is the timeline for a standard Level 1 Appeal?
» What happens after Peoples Health decides on a standard Level 1 Appeal?
» What are the requirements and timeline for a fast Level 1 Appeal?
» What happens after Peoples Health decides on a fast Level 1 Appeal?
» What happens with a Level 2 Appeal?
» What happens after the Independent Review Organization decides on a Level 2 Appeal?
Appeals for Prescription Drugs
» What is the timeline for a standard Level 1 Appeal?
» What happens after Peoples Health decides on a standard Level 1 Appeal?
» What are the requirements and timeline for a fast Level 1 Appeal?
» What happens after Peoples Health decides on a fast Level 1 Appeal?
» What happens with a Level 2 Appeal?
» What happens after the Independent Review Organization decides on a Level 2 Appeal?
Grievances (Complaints)
» What are grievances?
» How do I file a grievance?
» How does the grievance review process work?
What are appeals?
If you are unhappy with our organization determination for medical care coverage or our coverage determination for prescription drug coverage, you can submit an appeal.
An appeal is a formal way of asking us to review and change our organization determination or coverage determination. You would submit an appeal if you want us to reconsider and change a decision we have made about medical care or prescription drug benefits that are covered for you, or what we will pay for medical care or a prescription drug.
When you submit an appeal, we review the initial organization determination or coverage determination to see if we followed all of the rules properly. Your appeal is handled by different reviewers than those who made the organization determination or coverage determination. When we have completed the review we give you our decision.
- An appeal regarding an organization determination is also called a reconsideration.
- An appeal regarding a coverage determination is also called a redetermination.
How do you ask for an appeal?
You can ask for an appeal yourself, or your physician or someone you have legally appointed to act on your behalf may do it for you. This person would be called your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you, and you can do this by completing the Appointment of Representative Form.
Appointment of Representative Form
Download PDF (66 KB)
You may ask for either a “standard” appeal or a “fast” appeal. More information about standard appeals and fast appeals for medical coverage and prescription drug coverage is available on this page.
- Standard appeals must be made in writing by submitting a signed request.
- Fast appeals may be made in writing or by calling us.
Our contact information is listed below:
Peoples Health
Appeals and Grievances Department
Three Lakeway Center
3838 N. Causeway Blvd., Ste. 2200
Metairie, LA 70002
If you would like to use a standard form to submit your appeal request regarding a prescription drug (reconsideration) to us in writing, use the Request for Redetermination of Medicare Prescription Drug Denial Form.
Request for Redetermination of Medicare Prescription Drug Denial Form
– Phone
TTY users may call 711
Seven days a week, from 8 a.m. to 8 p.m. If you contact us on a weekend or on a holiday between February 15 and September 30, you may leave a message, and your call will be returned within one business day.
(504) 849-6959 – Fax
You may also file an appeal online using the Request for an Appeal or Redetermination Form.
Request for an Appeal or Redetermination Form
Online Form
You must submit your appeal request within 60 calendar days from the date on the written notice we sent with our answer to your original request for an organization determination or coverage determination. If you miss the deadline and there is a good reason for missing it, we may give you more time to submit an appeal. Your first appeal is called a Level 1 Appeal.
Appeals for Medical Care
What is the timeline for a standard Level 1 Appeal?
For a standard Level 1 Appeal determination, we will give you an answer as quickly as your health condition requires but no later than 30 calendar days after we receive your appeal if your appeal is about services you have not yet received. We will give you an answer as quickly as your health condition requires but no later than 60 calendar days after we receive your appeal if your appeal is for reimbursement for medical care you have already received or paid for yourself.
However, if your appeal is about services you have not yet received and we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more calendar days to make our decision. We will let you know if we decide to do this. If you believe we should not take extra days, you can file a “fast” grievance, and we will give you an answer to your grievance within 24 hours. For more information about grievances, see Grievances.
If we do not give you our answer for an appeal about services you have not yet received within 30 calendar days; or an appeal about payment for services you have already received within 60 days; or, if there was an extended review period, by the end of that period, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal. For more information about Level 2 Appeals, see What happens with a Level 2 Appeal?.
What happens after Peoples Health decides on a standard Level 1 Appeal?
If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 30 days after we receive your appeal.
If you requested us to pay you back for medical care you already received and our answer is “YES” to all or part of what you requested, we are required to send you payment within 60 calendar days after we receive your appeal.
If our answer is “NO” to part or all of what you requested, we will send you a written notice informing you that we have automatically sent your appeal to the Independent Review Organization as a Level 2 Appeal. See What happens with a Level 2 Appeal?.
What are the requirements and timeline for a fast Level 1 Appeal?
If your health requires it, you can ask us for a “fast” appeal. To get a fast appeal, you must meet two requirements:
- You must be asking for coverage for medical care you have not yet received. You cannot ask for a fast appeal if your request is about medical care you have already received.
- Using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If your doctor tells us that your health requires a fast appeal, we will automatically agree to give you a fast appeal.
If you ask for a fast appeal on your own without your doctor’s support, we will decide whether your health requires that we give you a fast appeal. If we decide your medical condition does not meet the requirements for a fast appeal, we will process your request as a standard appeal and notify you of our decision to process your request as a standard appeal by calling you and by sending you a letter. Our notification will indicate that we will automatically give you a fast appeal if your doctor requests it. You will also be provided with information about your right to file a “fast” grievance about our decision to give you a standard appeal instead of a fast appeal. For more information about grievances, see Grievances (Complaints).
For a fast Level 1 Appeal, we will give you an answer as quickly as your health condition requires but no later than 72 hours after we receive your appeal. However, if we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more calendar days to make our decision. We will let you know if we decide to do this. If you do not agree with our decision to take more time, you may file an expedited grievance. See Grievances (Complaints) for more information. If we do not give you our answer within 72 hours (or, if there was an extended review period, by the end of that period), we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal. For more information about Level 2 Appeals, see What happens with a Level 2 Appeal?.
What happens after Peoples Health decides on a fast Level 1 Appeal?
If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 72 hours after we receive your appeal.
If our answer is “NO” to part or all of what you requested, we will notify you verbally and send you a written notice informing you that we have automatically sent your appeal to the Independent Review Organization as a Level 2 Appeal. See What happens with a Level 2 Appeal?.
What happens with a Level 2 Appeal?
The Independent Review Organization will review your appeal. This organization is hired by Medicare and is not connected with Peoples Health. We send the information about your appeal to the organization. You have the right to provide the organization with additional information.
If you had a standard Level 1 Appeal, you will have a standard Level 2 Appeal.
- The organization must give you an answer within 30 calendar days of when it receives your appeal.
- If the organization needs to gather more information that may benefit you, it can take up to 14 more calendar days.
If you had a fast Level 1 Appeal, you will have a fast Level 2 Appeal.
- The organization must give you an answer within 72 hours of when it receives your appeal.
- If the organization needs to gather more information that may benefit you, it can take up to 14 more calendar days.
What happens after the Independent Review Organization decides on a Level 2 Appeal?
If their answer is “YES” to all or part of what you requested, we must authorize the coverage within 72 hours or provide the service within 14 calendar days after we receive the organization’s decision.
- If their answer is “YES” to your request about a payment we denied for medical services, we are required to send the payment you have requested within 30 calendar days to you or the provider.
- If their answer is “NO” to part or all of what you requested, it means they agree with us that your request or part of your request should not be approved. The organization will send you a written notice that tells you the dollar value that must be in dispute for you to continue with the appeals process. If your case meets these requirements, you decide if you would like to continue the appeals process.
Appeals for Prescription Drugs
What is the timeline for a standard Level 1 Appeal?
For a standard Level 1 Appeal determination, we will give you an answer as quickly as your health condition requires but no later than 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 requires it.
- If we do not give you our answer within 7 calendar days, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal. See What happens with a Level 2 Appeal?.
What happens after Peoples Health decides on a standard Level 1 Appeal?
If you requested coverage for a drug and our answer is “YES,” we must provide the coverage we have agreed to provide as quickly as your health condition requires, but no later than 7 calendar days after we receive your appeal.
If you requested us to pay you back for a drug you already bought and our answer is “YES,” we are required to send you payment within 30 calendar days after we receive your appeal.
If our answer is “NO” to part or all of what you requested, we will send you a written notice that indicates why. This notice will also provide information on how to appeal your decision as a Level 2 Appeal. See What happens with a Level 2 Appeal?.
What are the requirements and timeline for a fast Level 1 Appeal?
If your health requires it, you can ask us for a “fast” appeal. To get a fast appeal, you must meet two requirements:
- You must be asking for a drug you have not yet received. You cannot ask for a fast appeal if you are asking us to pay you back for a drug you already bought.
- Using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If your doctor tells us that your health requires a fast appeal, we will automatically agree to give you a fast appeal.
If you ask for a fast appeal on your own without your doctor’s support, we will decide whether your health requires that we give you a fast appeal. If we decide your medical condition does not meet the requirements for a fast appeal, we will process your request as a standard appeal and notify you of our decision to process your request as a standard appeal by calling you and by sending you a letter. Our notification will indicate that we will automatically give you a fast appeal if your doctor requests it. You will also be provided with information about your right to file a “fast” grievance about our decision to give you a standard appeal instead of a fast appeal. For more information about grievances, see Grievances (Complaints).
For a fast Level 1 Appeal, we will give you an answer as quickly as your health condition requires but no later than 72 hours after we receive your appeal. If we do not give you our answer within 72 hours, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal. See What happens with a Level 2 Appeal?.
What happens after Peoples Health decides on a fast Level 1 appeal?
If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 72 hours after we receive your appeal.
If our answer is “NO” to part or all of what you requested, we will notify you verbally and send you a written notice informing you that we have automatically sent your appeal to the Independent Review Organization as a Level 2 Appeal. See What happens with a Level 2 Appeal?.
What happens with a Level 2 Appeal?
If we say no to your appeal, you then choose whether to accept this decision or continue by submitting another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed.
To file a Level 2 Appeal, you must contact the Independent Review Organization listed in the notice we sent you when we said “NO” to your Level 1 Appeal. This notice also includes instructions on how to file a Level 2 Appeal, including deadlines for contacting the organization. If you do file a Level 2 Appeal, we will send the information we have about your appeal to the organization.
For a standard Level 2 Appeal, the organization must give you an answer within 7 calendar days of when it receives your appeal.
If your health requires it, you may ask the organization for a fast Level 2 Appeal. If the organization agrees to a fast appeal, it must give you an answer within 72 hours of when it receives your appeal.
What happens after the Independent Review Organization decides on a Level 2 Appeal?
If your appeal was for coverage of a drug and their answer is “YES” to all or part of what you requested, we must provide the drug coverage:
- Within 72 hours after we receive the organization’s decision if it was a standard Level 2 Appeal
- Within 24 hours after we receive the organization’s decision if it was a fast Level 2 Appeal
If your appeal was for us to pay you back for a drug you already bought and their answer is “YES” to all or part of what you requested, we must send payment to you within 30 calendar days after we receive the organization’s decision.
If their answer is “NO” to part or all of what you requested, it means they agree with us that your request or part of your request should not be approved. The organization will send you a written notice that tells you the dollar value that must be in dispute for you to continue with the appeals process. If your case meets these requirements, you decide if you would like to continue the appeals process.
There are three additional levels to the appeals process after a Level 2 Appeal, for a total of five levels of appeal. There is also a separate appeals process if you would like us to cover a longer inpatient hospital stay or would like us to keep covering home health care, skilled nursing facility services or comprehensive outpatient rehabilitation facility services.
For detailed information about the general appeals process, the additional levels of appeal and the specific appeals process for the services noted above, please refer to Chapter 9 of your plan’s Evidence of Coverage. You can access your plan’s Evidence of Coverage, and other plan documents, electronically here.
Grievances (Complaints)
What are grievances?
A grievance is any complaint (other than an organization determination or coverage determination) related to your health plan or healthcare provider, including problems related to quality of care, waiting times and customer service, among others. A grievance is not used for requesting a coverage decision for benefits, coverage or payment. You can find more information about coverage decisions on the Coverage Decisions page.
For example, you would file a grievance if you:
- Are unhappy with the quality of care you have received
- Believe your privacy was not respected
- Are unhappy with or have experienced disrespect from a provider or our plan
- Are having difficulties making a doctor’s appointment
- Are unhappy with the cleanliness or condition of a doctor’s office or network pharmacy
- Believe our plan has not given you a notice you are required to receive or gave you information you believe was hard to understand
You can also file a complaint if you think our plan is not responding quickly enough to or meeting deadlines for a coverage decision request.
How do I file a grievance?
We encourage you to first call Member Services if you are having one of these problems. We will try to resolve any grievance that you might have over the phone. If you request a written response to your phone grievance, we will respond in writing to you.
If you are not satisfied with our response or if we cannot resolve your grievance over the phone, or if you do not wish to call us, you may submit your grievance online using the Grievance or Complaint Form; via fax using the fax number provided in the How does the grievance review process work? section; or via mail using the address provided in the How does the grievance review process work? section.
Grievance or Complaint
Please note: Whether you call or write, you should contact Member Services right away. Most grievances must be made within 60 days of the problem or event.
How does the grievance review process work?
The Peoples Health grievance review process is as follows:
- Most formal grievances should be directed to our Appeals and Grievances department within 60 days of the event prompting the complaint. Complaints related to quality of care may be submitted at any time.
- All grievances are investigated and responded to within 30 calendar days of the date the grievance was received. In some instances we will need additional time to address your concern. If additional time is needed, we may extend the timeframe by up to 14 days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. We will send you a written notice explaining the decision to take an extension.
- Grievances that involve the plan’s decision not to grant a fast decision or the plan’s decision to take an extension will be resolved in 24 hours.
- All grievances are investigated and responded to within 30 calendar days of the date the grievance was received. In some instances we will need additional time to address your concern. If additional time is needed, we may extend the timeframe by up to 14 days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. We will send you a written notice explaining the decision to take an extension.
- If you are dissatisfied with the response to your grievance, you can request a review in writing to our plan. Your review request may include written information from you or any other party of interest. You must submit the review request within 60 days of receiving the original resolution.
- If you disagree with the decision, your next step is to submit the dispute to binding arbitration in Jefferson Parish, state of Louisiana, under the prevailing commercial arbitration rules of the American Arbitration Association and judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. Any party desiring arbitration shall serve written notice thereof. Regulatory orders or requirements shall not be subject to arbitration. The demand shall be made within a reasonable time after the claim, dispute or other matter in question has arisen. The arbitrator shall have the authority and the power to render any judgment or relief available to a civil judge acting in Louisiana, including, without limitation, monetary damages, injunctive relief, attorney’s fees and costs to the prevailing party, etc.
For further information regarding the purpose and operations of the grievance review process, contact the following:
Peoples Health
Appeals and Grievances Coordinator
Three Lakeway Center
3838 N. Causeway Blvd., Suite 2200
Metairie, LA 70002
TTY users may call 711
Seven days a week, from 8 a.m. to 8 p.m. If you contact us on a weekend or on a holiday between February 15 and September 30, you may leave a message, and your call will be returned within one business day.
(504) 849-6959 – Fax
If you are filing a grievance because we denied your request for a “fast” decision for a coverage decision (organization determination or coverage determination) or a “fast” appeal, we will automatically give you a “fast” complaint. This means we will give you an answer within 24 hours.
When you file a complaint, we will answer you right away, if possible. Most complaints are answered within 30 calendar days. If we need more information that may benefit you, or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint.
Important Links, Documents and Forms
Links to Plan Documents
» Peoples Health Choices 65 (HMO)
» Peoples Health Choices Plus (HMO)
» Peoples Health Choices Select (HMO)
» Peoples Health Secure Choice (HMO SNP)
» Peoples Health Secure Health (HMO SNP)
» Peoples Health Group Medicare (HMO-POS)Appointment of Representative Form
Request for Redetermination of Medicare Prescription Drug Denial Form
Grievance or Complaint Form
Request for an Appeal or Redetermination Form
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