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PPO Appeals Grievance and Exception Process

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.

Grievance

A "grievance" is the type of complaint you make if you have any other type of problem with Presbyterian Insurance Company, Inc. or Presbyterian MediCare PPO or one of our plan practitioners and 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.

How to file a Grievance:

If you have a complaint, we encourage you to first call Member Services at (505) 923-6060 or toll-free, 1-800-797-5343 or TTY/TDD users should call 1-888-625-8818, Monday through Sunday 8 a.m. to 8 p.m. with any questions. We will try to resolve any complaint that you might have over the phone, or, you may submit a written complaint. We have a formal procedure to review your complaints. We call this our formal grievance process. Once we receive your grievance, Presbyterian Health Plan will write you to let you know how we have addressed your concern within fifteen (15) working days after we receive your grievance. In some instances, we may need additional time to address your concern. If additional time is needed, we will keep you informed of how your grievance is being handled. No matter which process you use to notify Presbyterian Health Plan, we must keep track of all grievances or complaints in order to report our data to CMS and to our members, upon request.

You may send your grievance request letter to:

Grievance and Appeals Coordinator
Presbyterian MediCare PPO
P.O. Box 27489
Albuquerque, NM 87125-7489
Or Fax to: (505) 923-5124

Appeal

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 are covered for you or what we will pay for.

  1. A Medical Director Appeal may be filed when you are not satisfied with a Presbyterian Medical Director decision that either denied or limited a medical service. You appeal request must be submitted in writing.
  2. An Initial Appeal Review may be filed when you are not satisfied with any other Presbyterian decision that was not made by a Medical Director, and did not deny or limit a medical service. Example: How Presbyterian paid a claim. You appeal request must be submitted in writing.
  3. A Fast Appeal may be requested only when it is an emergency medical issue. This type of appeal is for those cases in which a longer time to reach a decision may increase the medical risk to the Member. This does not apply to issues such as the request to change a decision regarding how a claim was paid. Your appeal request may be submitted in writing or may be submitted verbally by calling the Member Services Department at 1-800-797-5343 or TTY/TDD users should call 1-888-625-8818.

How to file an Appeal:

Initial Appeals: You may call our Member Services Department to start the appeal process or you may send a letter to the Appeals Coordinator. Presbyterian must receive the Member's appeal request within 60 days of the action or decision that is being appealed. You may contact Member Services at (505) 923-6060 or toll-free, 1-800-797-5343 or TTY/TDD users should call 1-888-625-8818, with any questions. The appeal request should clearly explain the nature of the Appeal. You should include any of the following that you feel may help your appeal: medical records, medical literature, medical bills, expense records, and written statements or letters from you or a health care Provider.

You can submit a written appeal request letter to:

Grievance and Appeals Coordinator
Presbyterian MediCare PPO
P.O. Box 27489
Albuquerque, NM 87125-7489

Fast Appeal Requests may also be submitted by calling the Appeals department at (505) 923-6060 or toll free at 1-800-797-5343, Monday through Sunday 8 a.m. to 8 p.m.. Expedited appeals may also be faxed (505) 923-5124. 

Exceptions

How can you request an exception to the Plan's formulary?

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover your drug even if it is not on our formulary.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a Highest Tier Name drug, you can ask us to cover it as a Lower Tier Name instead. This would lower the co-payment amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

To request an exception, you or your appointed representative should call Presbyterian MediCare PPO Appeals at (505) 923-6060 or toll free at 1-800-797-5343 or TTY/TDD users should call 1-888-625-8818, Monday through Sunday 8 a.m. to 8 p.m. Your doctor can also fax this form to: (505) 923-5540.

Grievance and Appeals Coordinator
Presbyterian MediCare PPO
P.O. Box 27489
Albuquerque, NM 87125-7489

Medicare Prescription Drug Coverage Provider Communication Form

This form was developed to provide pharmacists with a form to be faxed to a beneficiary's physician when a requested medication is not covered by a plan sponsor. The form will allow the physician to consider whether to change the patient's prescription, seek prior authorization, or initiate the exceptions process. The form can also be used to seek prescription information from physicians immediately while the patient is waiting at the pharmacy.

Pharmacy Exception Review Process Form

Please refer to the MediCare PPO Drug Plan EOC for additional information on:

  • Exceptions - Section 6
  • Grievances - Section 10
  • Appeals - Section 11
  • Coverage Determinations - Section 12

Appointment of Representative

To download an Appointment of Representative form go to:

http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf. 

A party may appoint a representative if he or she wants assistance with their appeal. A physician or supplier may act as a beneficiary's appointed representative. A party may appoint a representative to act on his or her behalf by completing Form CMS-1696, Appointment of Representative (AOR), which is available at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf on the CMS website. A party may also appoint a representative through a submission that meets the following requirements:

  • It is in writing and is signed and dated by both the party and the individual who is agreeing to be the representative;
  • It includes a statement appointing the representative to act on behalf of the party and if the party is a beneficiary, authorizing the adjudicator to release identifiable health information to the appointed representative;
  • It includes a written explanation of the purpose and scope of the representation;
  • It contains the name, telephone number, and address of both the party and the appointed representative;
  • If the party is a beneficiary, the beneficiary's Medicare HIC number; 
  • It indicates the appointed representative's professional status or relationship to the party; and
  • It is filed with the entity that is processing the party's initial determination or appeal.

A representative may submit arguments, evidence, or other materials on behalf of the party. The representative, the party, or both may participate in all levels of the appeals process. Once both the party and the representative have signed the AOR Form, the appointment is valid for one year from the date of the last signature for the purpose of filing future appeals unless it has been revoked. 

As noted above, a beneficiary may also assign (transfer) his or her appeal rights to a physician or supplier who is not a party to the initial determination and who furnished the items or services at issue in the appeal. A beneficiary must assign appeal rights using the form CMS-20031, Transfer of Appeal Rights, available at http://www.cms.hhs.gov/cmsforms/downloads/cms20031.pdf on the CMS website. A physician or supplier who accepts assignment of appeal rights must waive the right to collect payment from the beneficiary for the items or services at issue in the appeal, with the exception of deductible and coinsurance amounts and when a valid Advance Beneficiary Notice is in effect.

  • Medicare Physician Guide: Chapter 7, Inquiries, Overpayment, and Appeals. Pg 4-5.