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Molina Medicare of New Mexico |
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| Molina Medicare - How to file
grievances and appeals |
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We encourage you to let us know right away if you
have questions, concerns, or problems related to your covered services or the
care you receive. Please call Member Services at 1-866-440-0127 Monday-Sunday
8:00 am – 8:00 pm, TTY/TDD users can call 1-800-346-4128. (Hours of
Operation: Monday through Sunday 8:00 a.m. to 8:00 p.m.)
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| Note that sections
10
and
11
of the EOC* do not apply to Part D prescription drug benefits. See
section12
of the EOC* for detailed information about how to make an appeal that involves
a request for Part D drug benefits.
[*EOC: Links in this section go to the 2007 Evidence of Coverage. 2008 Evidence of Coverage is coming soon] |
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This section gives the rules for making complaints in different types of
situations. Federal law guarantees your right to make complaints if you have
concerns or problems with any part of your
medical care as a plan member. The Medicare program has helped set the rules
about what you need to do to make a complaint and what we are required to do
when we receive a complaint. If you make a complaint, we must be fair in how we
handle it. You cannot be disenrolled from Molina Medicare or penalized in any
way if you make a complaint. |
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| What are appeals and grievances? |
You have the right to make a complaint if you have
concerns or problems related to your coverage or care. "Appeals" and
grievances" are the two different types of complaints you can
make. |
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An "appeal" is the type of complaint you make when you
want us to reconsider and change a decision we have made about what services or
benefits are covered for you or what we will pay for a service or benefit. For
example, if we refuse to cover or pay for services you think we should cover,
you can file an appeal. If Molina Healthcare of New Mexico or one
of our plan providers refuses to give you a service you think should be
covered, you can file an appeal. If Molina Healthcare of New Mexico or one of
our plan providers reduces or cuts back on services or benefits you have been
receiving, you can file an appeal. If you think we are stopping your coverage
of a service or benefit too soon, you can file an appeal. |
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A "grievance" is the type of complaint you make if you
have any other type of problem with Molina Healthcare of New Mexico/Molina
Medicare or one of our plan providers. For example, you would file a grievance
if you have a problem with things such as the quality of your care, waiting
times for appointments or in the waiting room, the way your doctors or others
behave, being able to reach someone by phone or get the information you need,
or the cleanliness or condition of the doctor's office. |
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| To obtain information on the number of
grievances, appeals, and exceptions filed with Molina Options Plus please call
1-866-440-0127 Monday-Sunday 8:00 am - 8:00 pm, TTY/TDD users can call
1-800-346-4128. (Hours of Operation: Monday through Sunday 8:00 a.m. to 8:00
p.m.) |
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This section tells how to make complaints in different situations |
| The rest of this section has separate parts that
tell you how to make a complaint in each of the following situations: |
| 1. |
Complaints about what we will cover for you or what we
will pay for. If Molina Healthcare of New Mexico or your doctor or another plan
provider has refused to give you a service you think is covered, you can make a
complaint called an appeal. If we have
refused to pay for a service you think is covered for you, you can make an
appeal. If you have been receiving a covered service, and you think that
service is being reduced or ending too soon, you can make an appeal. When you
file an appeal, you are asking us to reconsider and change a decision we have
made about what services we will cover for you (which includes whether we will
pay for your care or how much we will pay).q |
| 2. |
Complaints about your Part D prescription drug
benefits that we will cover or pay for. If Molina Healthcare of New Mexico
refused to give you a Part D prescription drug benefit that you think is
covered, you can request an appeal. If we have refused to pay for a Part D
prescription drug that you have already received and you believe that it is
covered, you can make an appeal. If you have been receiving a Part D
prescription drug, and you think its coverage is being reduced or ending too
soon, you can make an appeal. When you file an appeal, you are asking us
to reconsider and change a decision we have made about what Part D prescription
drug we will cover for you (which includes whether we will pay for a Part D
prescription drug that you have already received, or how much we will pay). The
rules that apply to appeals of drug coverage are different than the rules that
apply to your health benefits. Be sure to read Section 6 so that you clearly
understand the difference. |
| 3. |
Complaints if you think you are being discharged from
the hospital too soon. There is a special type of appeal that applies only to
hospital discharges. If you think our coverage of your hospital stay is ending
too soon, you can appeal directly and immediately to New Mexico Peer Review
Organization, which is the Quality Improvement Organization in the state of New
Mexico. New Mexico Peer Review Organization is a group of health professionals
in your state that is paid to handle this type of appeal from Medicare
patients. If you make this type of appeal, your stay may be covered during the
time period the QIO uses to make its determination. You must act very quickly
to make this type of appeal, and it will be decided quickly. |
| 4. |
Complaints if you think your coverage for Skilled
Nursing Facility (SNF), Home Health (HHA) or Comprehensive Outpatient
Rehabilitation Facility (CORF) services is ending too soon. There is another
special type of appeal that applies only when coverage will end for SNF, HHA or
CORF services. If you think your coverage is ending too soon, you can appeal
directly and immediately to New Mexico Peer Review Organization, which is the
Quality Improvement Organization in the state of New Mexico. If you make this
type of appeal, your stay may be covered during the time period the QIO uses to
make its determination. You must act very quickly to make this type of appeal,
and it will be decided quickly. |
| 5. |
Complaints about any other type of problem you have
with Molina Healthcare of New Mexico, Inc./Molina Medicare or one of our plan
providers. If you want to make a complaint about any type of problem other than
those that are listed above, a grievance is the type of complaint you would
make. For example, you would file a grievance to complain about problems with
the quality or timeliness of your care, waiting times for appointments or in
the waiting room, the way your doctors or others behave, being able to reach
someone by phone or get the information you need, or the cleanliness or
condition of the doctor's office. Generally, you would file the grievance with
Molina Healthcare of New Mexico. But for many problems related to quality of
care you get from plan providers, you can also complain to New Mexico Peer
Review Organization. |
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Part 1. Complaints (appeals) to Molina Healthcare of New Mexico to change a
decision about what services we will cover or what we will pay for |
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This part explains what you can do if you have problems getting the medical
care you believe we should provide. We use the word "provide" in a general way
to include such things as authorizing care, paying for care, arranging for
someone to provide care, or continuing to provide a medical treatment you have
been getting. Problems getting the medical care you believe we should provide
include the following situations: |
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If you are not getting the care you want, and you
believe that this care is covered by Molina Medicare. |
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If we will not authorize the medical treatment your
doctor or other medical provider wants to give you, and you believe that this
treatment is covered by Molina Medicare. |
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If you are being told that coverage for a treatment or
service you have been getting will be reduced or stopped, and you feel that
this could harm your health. |
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If you have received care that you believe was covered
by Molina Medicare while you were a member, but we have refused to pay for this
care. |
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| Six possible steps for requesting care or payment
from Molina Medicare: |
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If you are having a problem getting care or payment for care, there are six
possible steps you can take to ask for the care or payment you want from us. At
each step, your request is considered and a decision is made. If you are
unhappy with the decision, you may be able to take another step if you want to
continue requesting the care or payment. |
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In Steps 1 and 2, you make your request directly to
us. We review it and give you our decision. |
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In Steps 3 through 6, people in organizations that are
not connected to us make the decisions about your request. To keep the review
independent and impartial, those who review the request and make the decision
in Steps 3 through 6 are part of (or in some way connected to) the Medicare
program or the federal court system. |
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| The six possible steps are summarized below
(they are covered in more detail in Section 11). |
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Step 1: The initial decision by Molina Healthcare of New Mexico |
| The starting point is when we make an "initial
decision" (also called an "organization determination") about your medical care
or about paying for care you have already received. When we make an "initial
decision," we are giving our interpretation of how the benefits and services
that are covered for members of Molina Medicare apply to your specific
situation. As explained in Section 11, you can ask for a "fast initial
decision" if you have a request for medical care that needs to be decided more
quickly than the standard time frame. |
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| Step 2: Appealing the initial decision by Molina
Healthcare of New Mexico |
If you disagree with the decision we make in Step
1, you may ask us to reconsider our decision. This is called an "appeal" or a
"request for reconsideration." As explained in Section 11, you
can ask for a "fast appeal" if your request is for medical care and it needs to
be decided more quickly than the standard time frame. After reviewing your
appeal, we will decide whether to
stay with our original decision, or change this decision and give you some or
all of the care or payment you want. |
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| Step 3: Review of your request by an Independent
Review Organization |
| If we turn down part or all of your request in
Step 2, we are required to send your request to an independent review
organization that has a contract with the federal government and is not part of
Molina Healthcare of New Mexico. This organization will review your request and
make a decision about whether we must give you the care or payment you want. |
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| Step 4: Review by an Administrative Law Judge |
| If you are unhappy with the decision made by the
independent review organization that reviews your case in Step 3, you may ask
for an Administrative Law Judge to consider your case and make a decision. The
Administrative Law Judge works for the federal government. The dollar value of
your contested benefit must be at least $110.00 to be considered in Step 4. |
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| Step 5: Review by a Medicare Appeals Council |
| If you or we are unhappy with the decision made in
Step 4, either of us may be able to ask a Medicare Appeals Council to review
your case. This Council is part of the federal department that runs the
Medicare program. |
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| Step 6: Federal Court |
| If you or we are unhappy with the decision made by
the Medicare Appeals Council in Step 5, either of us may be able to take your
case to a Federal Court. The dollar value of your contested medical care must
at least $1,090.00 to go to a Federal Court.
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| For a more detailed explanation of all six steps
outlined above, see Section 11. |
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| Part 2. Complaints (appeals) to Molina Healthcare
of New Mexico to change a decision about what Part D drugs we will cover or pay
for |
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This part explains what you can do if you have
problems getting the prescription drugs you believe we should provide. We use
the word "provide" in a general way to include
such things as authorizing prescription drugs, paying for prescription drugs,
or continuing to provide a Part D prescription drug that you have been getting.
Problems getting a Part D prescription drug that you believe we should provide
include the following situations: |
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If you are not able to get a prescription drug that
you believe may be covered by Molina Medicare. |
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If you have received a Part D prescription drug you
believe may covered by Molina Medicare while you were a member, but we have
refused to pay for the drug. |
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If we will not provide or pay for a Part D
prescription drug that your doctor has prescribed for you because it is not on
our formulary. |
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If you disagree with the amount that we require you to
pay for a Part D prescription drug that your doctor has prescribed for you. |
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If you are being told that coverage for a Part D
prescription drug that you have been getting will be reduced or stopped. |
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If there is a requirement that you try another drug
before we pay for the drug your doctor prescribed, or if there is a limit on
the quantity (or dose) of the drug and you disagree with the requirement or
dosage limitation. |
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| Six possible steps for requesting a Part D benefit
or payment from Molina Medicare |
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| If you are having a problem getting a Part D
benefit or payment for a Part D prescription drug that you have already
received, there are six possible steps you can take to ask for the benefit or
payment you want from us. At each step, your request is considered and a
decision is made. If you are unhappy with the decision, you may be able to take
another step if you want to continue requesting the benefit or payment. |
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In Steps 1 and 2, you make your request directly to
us. We review it and give you our decision. |
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In Steps 3 through 6, people in organizations that are
not connected to us make the decisions about your request. To keep the review
independent and impartial, those who review the request and make the decision
in Steps 3 through 6 are part of (or in some way connected to) the Medicare
program or the federal court system. |
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| The six possible steps are summarized below
(they are covered in more detail in Section 12). |
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| Step 1: The initial decision by Molina Healthcare
of New Mexico |
| The starting point is when we make an "initial
decision" (also called a "coverage determination") about your Part D
prescription drug or about paying for Part D drug that you have already
received. When we make an "initial decision," we are giving our interpretation
of how the benefits that are covered for members of Molina Medicare apply to
your specific situation. As explained in Section 12, you can ask for a "fast
initial decision" if you have a request for benefits that needs to be decided
more quickly than the standard time frame. |
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Step 2: Appealing the initial decision by Molina Healthcare of New Mexico |
| If you disagree with the decision we make in Step
1, you may ask us to reconsider our decision. This is called an "appeal" or a
"request for redetermination." As explained in Section 12, you can ask for a
"fast appeal" if your request for benefits needs to be decided more quickly
than the standard time frame. After reviewing your appeal, we will decide
whether to stay with our original decision, or change this decision and give
you the benefit or payment you want. |
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| Step 3: Review of your request by an Independent
Review Organization |
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If we turn down your request in Step 2, you may ask an independent review
organization to review our decision. The independent review organization has a
contract with the federal government and is not part of Molina Healthcare of
New Mexico. The independent review organization will review your request and
make a decision about whether we must give you the benefit or payment you want. |
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| Step 4: Review by an Administrative Law Judge |
| If you are unhappy with the decision made by the
independent review organization that reviews your case in Step 3, you may ask
for an Administrative Law Judge to consider your case and make a decision. The
Administrative Law Judge works for the federal government. The dollar value of
your contested benefit must be at least $110.00 to be considered in Step 4. |
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| Step 5: Review by a Medicare Appeals Council |
| If you are unhappy with the decision made in Step
4, you may be able to ask the Medicare Appeals Council (MAC) to review your
case. The MAC is part of the federal department that runs the Medicare program. |
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| Step 6: Federal Court |
| If you are unhappy with the decision made by the
MAC in Step 5, you may be able to take your case to a Federal Court. The dollar
value of your contested benefit must be at least $1,090.00 to go to a Federal
Court. |
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| For a more detailed explanation of all six steps
outlined above, see Section 12. |
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| Part 3. Complaints (appeals) if you think you are
being discharged from the hospital too soon |
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| When you are hospitalized, you have the right to
get all the hospital care covered by Molina Medicare that is necessary to
diagnose and treat your illness or injury. The day you leave the hospital (your
"discharge date") is based on when your stay in the hospital is no longer
medically necessary. This part of Section 10 explains what to do if you believe
that you are being discharged too soon. |
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Information you should receive during your
hospital stay
When you are admitted to the hospital, someone at the hospital should give you
a notice called the Important Message from Medicare. This notice explains: |
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Your right to get all medically necessary hospital
services covered. |
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Your right to know about any decisions that the
hospital, your doctor, or anyone else makes about your hospital stay and who
will pay for it. |
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That your doctor or the hospital may arrange for
services you will need after you leave the hospital. |
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| Your right to appeal a discharge decision. Review
of your hospital discharge by the Quality Improvement Organization |
| If you think that you are being discharged too
soon, ask your health plan to give you a notice called the Notice of Discharge
& Medicare Appeal Rights. This notice will tell you: |
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Why you are being discharged. |
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The date that we will stop covering your hospital stay
(stop paying our share of your hospital costs). |
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What you can do if you think you are being discharged
too soon. |
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Who to contact for help. |
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| You (or someone you authorize) may be asked to
sign and date this document, to show that you received the notice. Signing the
notice does not mean that you agree that you are ready to leave the hospital -
it only means that you received the notice. If you do not get the notice after
you have said that you think you are being discharged too soon, be sure to ask
for it immediately. |
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| You have the right by law to ask for a review of
your discharge date. As explained in the Notice of Discharge & Medicare
Appeal Rights, if you act quickly, you can ask an outside agency called the
Quality Improvement Organization to review whether your discharge is medically
appropriate. |
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| What is the "Quality Improvement Organization"? |
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"QIO" stands for Quality Improvement Organization. The QIO, called New Mexico
Peer Review Organization in your state, is a group of doctors and other health
care experts paid by the federal government to check on and help improve the
care given to Medicare patients. They are not part of Molina Healthcare of New
Mexico or your hospital. There is one QIO in each state. QIOs have different
names, depending on which state they are in. The doctors and other health
experts in New Mexico Peer Review Organization review certain types of
complaints made by Medicare patients. These include complaints about quality of
care and complaints from Medicare patients who think the coverage for their
hospital stay is ending too soon. Section 1 tells how to contact the QIO. |
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| Getting a QIO review of your hospital discharge |
| If you want to have your discharge reviewed, you
must act quickly to contact the QIO. The Notice of Discharge & Medicare
Appeal Rights gives the name and telephone number of your QIO and tells you
what you must do. |
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You must ask the QIO for a "fast review" of whether
you are ready to leave the hospital. This "fast review" is also called a "fast
appeal" because you are appealing the discharge
date that has been set for you. |
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You must be sure that you have made your request to
the QIO no later than noon on the first working day after you are given written
notice that you are being discharged from the hospital. This deadline is very
important. If you meet this deadline, you are allowed to stay in the hospital
past your discharge date without paying for it yourself, while you wait to get
the decision from the QIO (see below). |
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| If the QIO reviews your discharge, it will first
look at your medical information. Then it will give an opinion about whether it
is medically appropriate for you to be discharged on the date that has been set
for you. The QIO will make this decision within one full working day after it
has received your request and all of the medical information it needs to make a
decision. |
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If the QIO decides that your discharge date was
medically appropriate, you will not be responsible for paying the hospital
charges until noon of the calendar day after the QIO gives you its decision. |
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If the QIO agrees with you, then we will continue to
cover your hospital stay for as long as medically necessary. |
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| What if you do not ask the QIO for a review by the
deadline? |
| You still have another option: asking Molina
Healthcare of New Mexico for a "fast appeal" of your discharge |
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| If you do not ask the QIO for a "fast review"
("fast appeal") of your discharge by the deadline, you can ask us for a "fast
appeal" of your discharge. How to ask us for a fast appeal is covered briefly
in the first part of this section and in more detail in Section 11. |
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If you ask us for a fast appeal of your discharge and you stay in the hospital
past your discharge date, you run the risk of having to pay for the hospital
care you receive past your discharge date. Whether you have to pay or not
depends on the decision we make. |
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If we decide, based on the fast appeal, that you need
to stay in the hospital, we will continue to cover your hospital care for as
long as medically necessary. |
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If we decide that you should not have stayed in the
hospital beyond your discharge date, then we will not cover any hospital care
you received if you stayed in the hospital after the discharge date. (Unless
the IRO overturns our decision.) |
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| You may have to pay if you stay past your discharge
date |
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If you stay in the hospital after your discharge date and do not ask for
immediate QIO review, you may be financially responsible for the cost of many
of the services you receive. However, you can appeal any bills for hospital
care you receive, using Step 1 of the appeals process described in Section 11. |
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| Part 4. Complaints (appeals) if you think your
coverage for SNF, home health, or comprehensive outpatient rehabilitation
facility services are ending too soon. |
When you are a patient in a SNF, Home Health Agency (HHA), or Comprehensive
Outpatient Rehabilitation Facility (CORF), you have the right to get all the
SNF, HHA or CORF care covered by Molina Medicare that is necessary to diagnose
and treat your illness or injury. The day we end your SNF, HHA or CORF coverage
is based on when your stay is no longer medically necessary. This part of
Section 10 explains what to do if you believe that your
coverage is ending too soon. |
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| Information you will receive during your SNF, HHA
or CORF stay |
If we decide to end our coverage for your SNF,
HHA, or CORF services, you will get written notice either from us or your
provider at least 2 calendar days before your coverage ends. You
(or someone you authorize) will be asked to sign and date this document to show
that you received the notice. Signing the notice does not mean that you agree
that coverage should end - it only means that you received the notice. |
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| How to get a review of your coverage by the Quality
Improvement Organization |
| You have the right by law to ask for an appeal of
our termination of your coverage. As will be explained in the notice you get
from us or your provider, you can ask the Quality Improvement Organization (the
"QIO") to do an independent review of whether our terminating your coverage is
medically appropriate. |
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How soon you have to ask the QIO to review your coverage? |
| If you want to have the termination of your
coverage appealed, you must act quickly to contact the QIO. The written notice
you got from us or your provider gives the name and telephone number of your
QIO and tells you what you must do. |
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If you get the notice 2 days before your coverage
ends, you must be sure to make your request no later than noon of the day after
you get the notice. |
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If you get the notice and you have more than 2 days
before your coverage ends, then you must make your request no later than noon
of the day before the date that your Medicare coverage ends. |
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| What will happen during the review? |
| If the QIO reviews your case, the QIO will ask for
your opinion about why you believe the services should continue. You do not
have to prepare anything in writing, but you may do so if you wish. The QIO
will also look at your medical information, talk to your doctor, and review
other information that we have given to the QIO. You and the QIO will each get
a copy of our explanation about why your services should not continue. |
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| After reviewing all the information, the QIO will
give an opinion about whether it is medically appropriate for your coverage to
be terminated on the date that has been set for you. The QIO will make this
decision within one full day after it receives the information it needs to make
a decision. |
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| What happens if the QIO decides in your favor? |
| If the QIO agrees with you, then we will continue
to cover your SNF, HHA or CORF services for as long as medically necessary. |
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| What happens if the QIO denies your request? |
| If the QIO decides that our decision to terminate
coverage was medically appropriate, you will be responsible for paying the SNF,
HHA or CORF charges after the termination date on the advance notice you got
from us or your provider. Neither Original Medicare nor Molina Healthcare
of New Mexico will pay for these services. If you stop receiving services on or
before the date given on the notice, you can avoid any financial liability. |
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| What if you do not ask the Medicare/Medicaid
Assistance Program (MMAP) for a review in time? |
| You still have another option: asking Molina
Healthcare of New Mexico for a "fast appeal" of your discharge. |
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| If you do not ask MMAP for a "fast appeal" of your
discharge by the deadline, you can ask us for a "fast appeal" of your
discharge. How to ask us for a fast appeal is covered briefly in the first part
of this section and in more detail in Section 11. |
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| If you ask us for a fast appeal of your
termination and you continue getting services from the SNF, HHA, or CORF, you
run the risk of having to pay for the care you receive past your termination
date. Whether you have to pay or not depends on the decision we make. |
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If we decide, based on the fast appeal, that you need
to continue to get your services covered, then we will continue to cover your
care for as long as medically necessary. |
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If we decide that you should not have continued
getting coverage for your care, then we will not cover any care you received if
you stayed after the termination date. |
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You may have to pay if you stay past your
discharge date, if MMAP does not decide in your favor. If you do not ask MMAP
by noon after the day you are given written notice that we will be terminating
coverage for your SNF, HHA or CORF services, and if you stay in the SNF, HHA or
CORF after this date, you run the risk of having to pay for the SNF, HHA or
CORF care you
receive on and after this date. However, you can appeal any bills for SNF, HHA
or CORF care you receive using Step 1 of the appeals process described in
Section 11 . |
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| Part 5. Complaints (grievances) about any other
type of problem you have with Molina Healthcare of New Mexico, Inc./Molina
Medicare or one of our plan providers |
This last part of Section 10 explains how to make
complaints about any other type of problem that has not already been discussed
earlier in this section. (The problems that have
already been discussed are problems related to coverage or payment for care or
Part D benefits, problems about being discharged from the hospital too soon,
and problems about coverage for SNF, HHA, or CORF services ending to soon.) |
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| What is included in "all other types of problems"? |
| Here are some examples of problems that are
included in this category of "all other types of problems": |
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Problems with the quality of the medical care you
receive, including quality of care during a hospital stay. |
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If you feel that you are being encouraged to leave
(disenroll from) Molina Medicare. |
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Problems with the Member Services you receive. |
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Problems with how long you have to spend waiting on
the phone, in the waiting room, or in the exam room. |
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Problems with getting appointments when you need them,
or having to wait a long time for an appointment. |
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Disrespectful or rude behavior by doctors, nurses,
receptionists, or other staff. |
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Cleanliness or condition of doctor's offices, clinics,
or hospitals. |
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| If you have one of these types of problems and
want to make a complaint, it is called "filing a grievance." In addition, you
have the right to ask for a "fast grievance" if you disagree with our decision
to not give you a "fast appeal" or if we take an extension on our initial
decision or appeal. See below for more detail. |
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| Filing a grievance with Molina Medicare |
If you have a complaint, we encourage you to first
call Member Services at the number on the cover of this booklet. We will try to
resolve any complaint that you might have over the phone.
If you request a written response to your phone complaint, we will respond in
writing to you. If we cannot resolve your complaint over the phone, we have a
formal procedure to review your complaints. We call this our Member Grievance
Process. |
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You must file your grievance within 60 days of the event that gives rise to the
grievance. You may file a grievance either orally or in writing, by one of the
methods below. Our business hours are Monday - Sunday, 8:00 am - 8:00 pm. |
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| CALL 1-866-440-0127.
This number is also on the cover of this booklet for easy Calls to this number
are free. |
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| TTY 1-800-346-4128. This
number requires special telephone equipment. It is on the cover of this booklet
for easy reference. Calls to this number are free. |
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| FAX 1-866-771-0117 |
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WRITE
Molina Medicare
ATTN: Grievance and Appeals Department
Union Park Center, Suite 300
Midvale, UT 84047 |
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| We will respond to all written grievances in
writing. We will respond to oral grievances orally, unless you specifically
request a written response. We will respond to all quality of care grievances
in writing, regardless of how the grievance was filed. |
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Expedited Grievance Procedure: You (or your
representative, with appropriate authorization) are entitled to an expedited
grievance whenever Molina Medicare takes an extension relating to an
organization determination, reconsideration, or when we refuse to expedite a
request for an organization determination or reconsideration. Molina Medicare
will respond to these grievances within 24 hours after receipt. Our expedited
grievance determination will address only your dissatisfaction with our
decision to take an extension or deny your request to expedite
a determination or appeal. The grievance determination will not address the
underlying issue (request for services or payment, etc.) that is the subject of
the organization determination or
reconsideration. |
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| Standard Grievance Procedure: For all other
grievances, we will make a decision and notify you of our decision as your case
requires based on your health status, but no later than 30 calendar days after
receiving your complaint. We may extend the timeframe by up to 14 calendar days
if you request the extension, or if we justify a need for additional
information and the delay is in your best interest. |
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| For quality of care problems, you may also complain
to the QIO |
| If you are concerned about the quality of care you
received, including care during a hospital stay, you can also complain to an
independent organization called the QIO. "QIO" stands for Quality Improvement
Organization. See Section 1 for more information about the QIO. |
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| Molina Medicare is an organization with a Medicare contract.
This contract is renewed annually, and coverage beyond the end of the contract
year is not guaranteed. |
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