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«Purpose: This chapter provides guidelines for understanding the complaint, grievance and appeal procedures used at Health Partners Plans. Topics:  ...»

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13

Health Partners Plans Provider Manual

Complaints, Grievances and Appeals

Purpose: This chapter provides guidelines for understanding the complaint, grievance and

appeal procedures used at Health Partners Plans.

Topics:

 Provider Disputes

 Provider Initiated Member Grievances and Appeals

 Sanctions and Appeals

 Medicaid Member Complaint & Grievance Process

 CHIP Member Complaint & Grievance Process

 Medicare Member Grievance & Appeal Process  PCO Member Complaint & Appeal Process Health Partners Plans Provider Manual Complaints, Grievances, and Appeals – Section 13 Page 13-1 Health Partners Plans Provider Manual Complaints, Grievances, and Appeals – Section 13 Page 13-2 Module Contents Overview 13-5 Provider Dispute & Appeal Process (Medicaid & PCO Only) 13-6 Disputes 13-6 1st Level Dispute Process 13-7 2nd Level Dispute Process (Internal Appeal) 13-7 Provider-Initiated Member Grievances/Appeals 13-8 Grievances (Act 68) (Medicaid and CHIP only) 13-9 Provider-Initiated Member Grievances - First-Level Review 13-10 Provider-Initiated Member Grievances - Second-Level Review 13-11 Expedited Grievances

–  –  –

Health Partners Essential Member Complaint & Appeal Process Complaints

First Level Complaint

Second Level Complaint

External Complaint Review

Expedited Complaints

Health Partners Plans Provider Manual Complaints, Grievances, and Appeals – Section 13 Page 13-3 Persons Whose Primary Language Is Not English

Persons with Disabilities

Appeals

Expedited Appeals

Fair Hearings

Expedited Fair Hearing

–  –  –

Health Partners Plans Provider Manual Complaints, Grievances, and Appeals – Section 13 Page 13-4 Overview Health Partners Plans provides several types of appeals to providers who are dissatisfied with our decisions. Depending on the nature of the issue, providers may be able to choose between more than one available appeal avenue. This section of the Provider Manual describes appeal options. Appeal options

include:

 Appeals of Inpatient Utilization Review  Provider Quality of Care Sanctions and Appeals (see Provider Quality of Care Sanctions and Appeals on page 9-7)  Health Partners Plans Provider Dispute and Appeal Process (Medicaid only) This process is only available to appeal decisions regarding credentialing denials, provider terminations by the plan, and provider claim denials. It may not be used to appeal decisions that regard medical necessity, or provider sanctions.

 Provider-Initiated Member Grievances (Act 68) With the member's consent, a provider may appeal (grieve) a Health Partners Plans decision on behalf of the member. A provider who pursues this appeal process may not additionally use the informal dispute resolution process described in Section V to appeal the same matter.

Health Partners Plans Provider Manual Complaints, Grievances, and Appeals – Section 13 Page 13-5 Provider Dispute & Appeal Process (Medicaid & PCO Only) This Provider Dispute & Appeal Process is available only for the Health Partners (Medicaid) and Health Partners Essential (PCO) plans, and may not be used for any issues concerning medical necessity decisions, nor for provider sanctions (see Provider Quality of Care Sanctions and Appeals on page 9-7).

A Provider Dispute is a written communication to Health Partners Plans from a Medicaid or PCO provider expressing dissatisfaction with a decision (other than a medical necessity decision or a provider sanction) that directly impacts the provider. The three matters that providers may bring through Health

Partners Plans' Provider Dispute & Appeal process are as follows:

 Provider credentialing denial by the plan;

 Provider termination action by the plan; and  Provider claim denials (for reasons other than medical necessity).

Providers are encouraged to follow the Claim Reconsideration process for quick resolution to billing and payment errors (see Claim Reconsiderations on page 12-23). Providers may, however, access the Dispute & Appeal Process for initial claim denials. If a Provider chooses to use the Dispute & Appeal Process for initial claim denials, the Dispute & Appeal Process filing deadlines apply, and the Claim Reconsideration process is no longer available as a resolution process.

Further, any initial claim denials presented through the Claim Reconsideration process that result in continued provider dissatisfaction may be presented through the Dispute & Appeal Process.

The Dispute & Appeal Process filing deadlines apply. The Provider Dispute & Appeal Process

provides for the settlement of applicable issues as follows:

Disputes Providers have the right to file a dispute regarding provider credentialing denial, provider termination, and claim denials (including denied payment for services already rendered). Providers have thirty (30) calendar days from the date of the written notice (credentialing denial, termination or claim denial) from Health

Partners Plans to file a dispute. All disputes must be in writing and mailed to:

Attn: Complaints, Grievances & Appeals Unit Health Partners Plans 901 Market Street, Suite 500 Philadelphia, PA 19107 A provider representative (i.e., co-worker, friend, the provider's attorney, etc.) can assist the provider in filing a dispute. If a provider representative files a dispute on behalf of a provider, the provider must provide Health Partners Plans with written authorization stating that said provider representative may act on the provider's behalf. The provider is given ten (10) calendar days to provide the proper authorization for said provider representation. The dispute process begins the date upon which the written authorization from the provider is received by Health Partners Plans' Complaints, Grievances & Appeals (CG&A) Unit.





Health Partners Plans Provider Manual Complaints, Grievances, and Appeals – Section 13 Page 13-6 1st Level Dispute Process The initial dispute is a 1st Level Dispute. After Health Partners Plans' Complaints, Grievances & Appeals Unit receives the request for the dispute process by the provider or the provider representative, Health Partners Plans will initiate the 1st Level Dispute panel. The panel will consist of at least one person who has the authority, training and expertise to address and resolve Provider Dispute issues. The 1st Level Dispute panel has thirty (30) calendar days from the date of receipt of the 1st Level Dispute request to investigate and render a decision. The Complaints, Grievances & Appeals Unit has five (5) business days from the date of the 1st Level Dispute panel's resolution to forward the decision notification letter to the provider.

If the provider is dissatisfied with the decision, the provider may appeal the dispute to Health Partners Plans' 2nd Level Dispute (Internal Appeal) process.

2nd Level Dispute Process (Internal Appeal) Following resolution of his/her 1st Level Dispute, a provider has the right to file a 2nd Level Dispute (Appeal). The 2nd Level Dispute (Appeal) by the provider is due within thirty (30) calendar days of the date of the 1st Level Dispute decision notification letter. All 2nd Level Disputes (Appeals) must be in

writing and mailed to:

–  –  –

The Complaints, Grievances & Appeals Unit will appoint a 2nd Level Dispute review committee which

shall:

 include healthcare providers/peers not employed by Health Partners Plans, comprising at least one-fourth (1/4) of the membership of the committee;

 include committee members who have the authority, training and expertise to address and resolve Provider Disputes (Appeals);

 have access to data necessary to assist committee members in making decisions; and  document meetings and decisions of the committee.

Prior to the 2nd Level Dispute (Appeal) hearing, Health Partners Plans will send a letter to the provider informing him/her of his/her right to appear before the 2nd Level Dispute (Appeal) panel. The provider's authorized representative (if applicable) also has the right to be present at the 2nd Level Dispute (Appeal) hearing. The provider must give the name of the provider representative to Health Partners Plans at least two (2) business days prior to the 2nd Level Dispute (Appeal) hearing. Additionally, the same rules apply for appointing a provider representative as described above in the "Disputes" section.

The 2nd Level Dispute (Appeal) panel has thirty (30) calendar days from the date of receipt of the 2nd Level Dispute (Appeal) request to hold a hearing and render a decision. The CG&A Unit has five (5) business days from the date of the 2nd Level Dispute (Appeal) panel's resolution to forward the decision notification letter to the provider. The decision of the 2nd Level Dispute (Appeal) Committee is final and binding.

Health Partners Plans Provider Manual Complaints, Grievances, and Appeals – Section 13 Page 13-7 Provider-Initiated Member Grievances & Appeals This information pertains to Health Partners (Medicaid), Health Partners Essential (PCO) and KidzPartners (CHIP) members. With the written permission of the member, providers have the right to appeal on behalf of the member. While a provider may request the member's written consent prior to treatment, he or she may not (as a condition of treatment) require that the member sign a document authorizing the provider to file a grievance.

Applicable regulations provide specific requirements and time frames that must be adhered to. When the member gives the provider permission to file a grievance or appeal, the provider must assure timely compliance with the requirements, since he or she has assumed the member's grievance and appeal rights.

The member, however, may rescind consent at any time.

When the provider initiates a member grievance or appeal, he or she may not bill the member for the services that are the subject of the grievance until an external grievance review has been completed, or unless the member has rescinded the consent. Health Partners (Medicaid) members may never be billed or balance billed for covered services.

In situations where the provider is prohibited from billing the member, or if the provider chooses to never bill the member for the services being grieved, he or she may drop the grievance. The provider must notify the member or the member's legal representative in order to do so.

A member may ask another person to serve as his/her representative in the appeal process. This person is then termed the "member's representative." If the representative is a healthcare provider, the provider must have the member's written consent to file/pursue a grievance or appeal. Either the member or the member's legal representative may provide this consent.

The written consent giving a provider authority to file/pursue a grievance or appeal as the member's

representative must contain each of the following:

 The member's name, address, date of birth, and plan identification number  When the member is a minor or legally incompetent: the name, address and relationship to the member of the person signing the consent on behalf of the member  The name, address and identification number of the healthcare provider who is obtaining consent from the member  The name and address of the plan that will receive the grievance or appeal  A description of the specific service(s) (whether coverage was provided or denied) that the consent will apply to  The signature and date of signature of the member, or (if a minor or legally incompetent) the member's legal representative; and the signature and date of signature of a witness

The written consent must also include the following statements:

 The member or member's legal representative may not file a grievance or appeal about the service(s) listed in the consent form unless the member or member's legal representative rescinds the consent in writing. The member or member's legal representative has the right to rescind this consent at any time during the grievance or appeal process.

Health Partners Plans Provider Manual Complaints, Grievances, and Appeals – Section 13 Page 13-8  If the provider fails to file the grievance or appeal, or does not continue to pursue the grievance or appeal through the second-level review process, the consent of the member or member's legal representative will be rescinded automatically.

 The member (or the member's legal representative, if the member is a minor or legally incompetent) has read (or has been read) this consent document, and has had it explained to his/her satisfaction. The member or member's legal representative understands the information in the member's consent form.

A member may rescind his/her consent at any time throughout the grievance and appeal process. If the member rescinds consent, he/she may continue the grievance from the point at which consent was rescinded. A member may not file a separate grievance or appeal on the same matter. If a member files a grievance or appeal, he/she may, at any time during the grievance or appeal process, choose to give consent to a healthcare provider to continue the grievance or appeal on behalf of the member. A member's legal representative may similarly exercise these member rights.

Please note that, if a provider uses the following process, he or she may not also use the informal dispute resolution process described under Appeals of Inpatient Utilization Review Decisions to appeal the same matter.

Under Pennsylvania Code Title 28, chapter 9- 9.706 (c) (g), (c), once a healthcare provider assumes responsibility for filing a grievance, the healthcare provider may not bill the enrollee or the enrollee’s legal representative for services provided that are the subject of the grievance until the external grievance review has been completed or the enrollee or the enrollee’s legal representative rescinds consent for the healthcare provider to pursue the grievance. If the healthcare provider chooses never to bill the enrollee or the enrollee’s legal representative for the services provided that are the subject of the grievance, the healthcare provider may drop the grievance with notice to the enrollee and the enrollee’s legal representative in accordance with subsection (g).



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