Optima Medicare (PPO): Grievance, Coverage Determination and Appeals Process for PART C Medical Services

If you are a member of Optima Medicare Plans (PPO), and you have a concern about your health plan, the quality of your care or your coverage for certain services, you may follow an established process to resolve your concern. You cannot be disenrolled from Optima Medicare plans or penalized in any way if you make a complaint.

What is a Grievance?

A grievance is any complaint, other than one that involves a request for an initial determination or an appeal.

An appeal is defined as any of the procedures that deal with the review of adverse organization determinations on the health care services you believe you are entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect your health), or on any amounts you must pay for a service. 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.

What types of problems might lead to your filing a grievance?

Problems with the service you receive from Member Services.
If you feel that you are being encouraged to leave (disenroll from) the Plan.
If you disagree with our decision not to give you a “fast” decision or a “fast” appeal.
We don’t give you a decision within the required time frame.
We don’t give you required notices.
You believe our notices and other written materials are hard to understand.
We don’t forward your case to the Independent Review Entity if we do not give you a decision on time.
Problems with the quality of the medical care or services you receive, including quality of care during a hospital stay.
Problems with how long you have to wait on the phone, in the waiting room, or in the exam room.
Problems getting appointments when you need them, or waiting too long for them.
Rude behavior by doctors, nurses, receptionists, or other staff.
Cleanliness or condition of doctor’s offices, clinics, or hospitals.

Who may file a grievance?

You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative.

If you would like to appoint a person to file a grievance, request a coverage determination, or request an appeal on your behalf, you and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request. The form can be found at the following web address:
http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf. Or, you can call Member Services at 1-800-927-6048 (TTY/TDD 1-800-828-1120) and we will send this form to you. Send the completed form to:

Optima Medicare (PPO)
Appeals Department
P. O. Box 62876
Virginia Beach, VA 23466-2876

Filing a grievance with our Plan

If you have a complaint, you or your representative may call 1-800-927-6048 (TTY/TDD 1-800-828-1120). We will try to resolve your complaint over the phone. If you ask for a written response, file a written grievance, or your complaint is related to quality of care, 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.

The grievance must be submitted within sixty (60) days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than thirty (30) days after receiving your complaint. We may extend the time frame by up to fourteen (14) days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.

Informal Complaints

An informal complaint may be appropriate if you want to make us aware of a problem or a concern with care you received from one of our providers but you don’t necessarily want the information shared with your provider, or you do not want your name used. Please follow these steps to file an informal complaint:

Call Member Services at 1-800-927-6048 (TTY/TDD 1-800-828-1120) and let us know about your concern(s). You should call as soon as possible within sixty (60) calendar days of the date of the occurrence(s).
The Member Services representative may ask you for additional information so that we may research the issue. We won’t contact your provider and you don’t have to give us your name. The information that you provide us about your complaint will be used for training and education purposes only.
We may follow up your phone call with a letter written to you stating that we received and processed your grievance as an informal complaint.

Formal Written Complaints

You may choose to file a formal written complaint. Formal complaints are thoroughly investigated by contacting all involved parties, including the provider of your service and obtaining all information regarding the issues. A formal complaint should be made in writing as soon as possible within sixty (60) calendar days of the occurrence. Please follow these steps to file a formal written complaint:

Formal complaints should always be in writing. Call Member Services at 1-800-927-6048 (TTY/TDD 1-800-828-1120) for a copy of instructions and complaint forms. Tell Member Services if you need help with writing your complaint, or if for some reason you are unable to file a written complaint. You may also obtain complaint forms and instructions by downloading and printing them from our website www.optimahealth.com.
Once you complete the written complaint form, it should be mailed to:
Optima Medicare (PPO)
Post Office Box 62876
Virginia Beach, VA 23466-2876.
You may also fax your written complaint form to Optima Health at 757-687-6232 or toll-free 1-866-472-3920.
You will receive a letter notifying you that your compliant has been received and about how long it will take to investigate the issues presented. Time frames for resolving complaints vary by the type of complaint. If your complaint is clinically urgent, the complaint will be addressed no later than one (1) business day after we receive all necessary information, including any additional information we request from you and any information we request from your provider. We will let you know how your complaint is resolved no later than seventy-two (72) hours from receipt of an urgent complaint. If your complaint is not clinically urgent, we will process your complaint and let you know how your complaint is resolved within thirty (30) calendar days of the date we receive your written complaint.

You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance. There is no filing limit for complaints concerning quality of care.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

You have the right to request a fast review or expedited grievance if you disagree with Optima Medicare’s decision to invoke an extension on your request for an organization determination or reconsideration, or the Plan's decision to process your expedited request as a standard request. In such cases, Optima Medicare will acknowledge your grievance within twenty-four (24) hours of receipt and notify you in writing of the Plan's decision within three (3) calendar days.

Fast Grievances

In certain cases, you have the right to ask for a “fast grievance,” meaning we will answer your grievance within twenty-four (24) hours.

Complaints and Appeals about your Part C Medical Care and Service(s)

Initial Determinations

The initial determination we make is the starting point for dealing with requests you may have about covering a Part C medical care or service you need, or paying for a Part C medical care or service you already received. Initial decisions about Part C medical care or services are called "organization determinations." With this decision, we explain whether we will provide the Part C medical care or service you are requesting, or pay for the Part C medical care or service you already received.

The following are examples of requests for initial determinations:

You are not getting Part C medical care or services you want, and you believe that this care is covered by the Plan.
We will not approve the medical treatment your doctor or other medical provider wants to give you, and you believe that this treatment is covered by the Plan.
You are being told that a medical treatment or service you have been getting will be reduced or stopped, and you believe that this could harm your health.
You have received Part C medical care or services that you believe should be covered by the Plan, but we have refused to pay for this care.

Who may ask for an initial determination?

You, your prescribing physician, or someone you name may ask us for an initial determination. The person you name would be your “appointed representative.” You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under State law to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative. You and your appointed representative need to complete the form (or a written equivalent) that can be found at the following web address: http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf. Or, you can call Member Services at 1-800-927-6048 (TTY/TDD 1-800-828-1120) and we will send this form to you. Send the completed form and your request to:

Optima Medicare (PPO)
Medical Care Services
4417 Corporation Lane
Virginia Beach, VA 23462

You also have the right to have a lawyer act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.

Asking for a “standard" or "fast" initial determination

A decision about whether we will give you, or pay for Part C medical care or service you are requesting can be a “standard" decision that is made within the standard time frame, or it can be a “fast" decision that is made more quickly. A fast decision is also called an “expedited" decision.

Asking for a standard decision

To ask for a standard decision for a Part C medical care or service you, your doctor, or your representative should fax, or write us at the numbers or address listed at the end of this information.

Asking for a fast decision

You may ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. (Fast decisions apply only to requests for benefits that you have not yet received. You cannot get a fast decision if you are asking us to pay you back for a benefit that you already received.)

Be sure to ask for a “fast” or “expedited” review. If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.

If you ask for a fast decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a “fast grievance.” You have the right to file a fast grievance if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast initial determination, we will give you a standard decision.

What happens when you request an initial determination?

For a decision about payment for Part C medical care or services you already received, if we do not need more information to make a decision, we have up to thirty (30) days to make a decision after we receive your request. However, a small number of decisions may take longer. If we need more information in order to make a decision, we have up to sixty (60) days from the date of the receipt of your request to make a decision. You will be told in writing when we make a decision. If you have not received an answer from us within sixty (60) days of your request, you have the right to appeal.
For a standard decision about Part C medical care or services you have not yet received, we have fourteen (14) days to make a decision after we receive your request. However, we can take up to fourteen (14) more days if you ask for additional time, or if we need more information (such as medical records) that may benefit you. If we take additional days, we will notify you in writing. If you believe that we should not take additional days, you can make a specific type of complaint called a “fast grievance”. If you have not received an answer from us within fourteen (14) days of your request (or by the end of any extended time period), you have the right to appeal.
For a fast decision about Part C medical care or services you have not yet received, we will give you our decision about your requested medical care or services within seventy-two (72) hours after we receive the request. However, we can take up to fourteen (14) more days if we find that some information is missing that may benefit you, or if you need more time to prepare for this review. If we take additional days, we will notify you in writing. If you believe that we should not take any extra days, you can file a fast grievance. We will call you as soon as we make the decision. If we do not tell you about our decision within seventy-two (72) hours (or by the end of any extended time period), you have the right to appeal. If we deny your request for a fast decision, you may file a "fast grievance."

What happens if we decide completely in your favor?

For a decision about payment for Part C medical care or services you already received, we generally must send payment no later than thirty (30) days after we receive your request. However, a small number of decisions may take up to sixty (60) days. If we need more information in order to make a decision, we have up to sixty (60) days from the date of the receipt of your request to make payment.
For a standard decision about Part C medical care or services you have not yet received, we must authorize or provide your requested care within fourteen (14) days of receiving your request. If we extended the time needed to make our decision, we will authorize or provide your medical care before the extended time period expires.
For a fast decision about Part C medical care or services you have not yet received, we must authorize or provide your requested care within seventy-two (72) hours of receiving your request. If we extended the time needed to make our decision, we will authorize or provide your medical care before the extended time period expires.

What happens if we decide against you?

If we decide against you, we will send you a written decision explaining why we denied your request. If an initial determination does not give you all that you requested, you have the right to appeal the decision.

Appeal Level 1: Appeal to the Plan

An appeal to the plan about Part C medical care or services is also called a plan "reconsideration."

Who may file your appeal of the initial determination?

If you are appealing an initial decision about Part C medical care or services, the rules about who may file an appeal are the same as the rules about who may ask for an organization determination.

How soon must you file your appeal?

You must file the appeal request within sixty (60) calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How to file your appeal?

Asking for a standard appeal: To ask for a standard appeal about a Part C medical care or service a signed, written appeal request must be sent to:
Optima Medicare (PPO)
Appeals Department
P. O. Box 62876
Virginia Beach, VA 23466-2876
Asking for a fast appeal: If you are appealing a decision we made about giving you a Part C medical care or service that you have not received yet, you and/or your doctor will need to decide if you need a fast appeal. You, your doctor, or your representative may ask us for a fast appeal by calling, faxing, or writing us at:
Optima Medicare (PPO)
Appeals Department
P.O. Box 62876
Virginia Beach, VA 23466-2876
Fax: 757-687-6232 or Toll-free Fax: 1-866-472-3920
Phone: 757-687-6404 or Toll-free Phone: 1-800-927-6048
TTY/TDD: 1-800-828-1120

To make a request for a fast appeal for Part C medical care or service outside of regular weekday business hours, please call the Optima Health Appeals Department at 757-687-6404 and leave a detailed message. Requests received outside of regularly scheduled business hours will receive priority attention the next business day. Be sure to ask for a "fast" or "72-hour" review.

Remember, if your doctor provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically give you a fast appeal. If you ask for a fast decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a “fast grievance.” You have the right to file a fast grievance if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast appeal, we will give you a standard appeal.

How soon must we decide on your appeal?

For a decision about payment for Part C medical care or services you already received, we have sixty (60) days to decide after we receive your appeal request. If we do not decide within sixty (60) days, your appeal automatically goes to Appeal Level 2.
For a standard decision about Part C medical care or services you have not yet received, we have thirty (30) days to decide after we receive your appeal. We will decide sooner if your health condition requires. However, if you ask for more time, or if we find that helpful information is missing, we can take up to fourteen (14) more days to make our decision. If we do not tell you our decision within thirty (30) days (or by the end of the extended time period), your request will automatically go to Appeal Level 2.
For a fast decision about Part C medical care or services you have not yet received, we have seventy-two (72) hours to decide after we receive your appeal. We will decide sooner if your health condition requires. However, if you ask for more time, or if we find that helpful information is missing, we can take up to fourteen (14) more days to make our decision. If we do not decide within seventy-two (72) hours (or by the end of the extended time period), your request will automatically go to Appeal Level 2.

What happens if we decide completely in your favor?

For a decision about payment for Part C medical care or services you already received, we must pay within sixty (60) days of receiving your appeal request.
For a standard decision about Part C medical care or services you have not yet received, we must authorize or provide your requested care within thirty (30) days of receiving your appeal request. If we extended the time needed to decide your appeal, we will authorize or provide your requested care before the extended time period expires.
For a fast decision about Part C medical care or services you have not yet received, we must authorize or provide your requested care within seventy-two (72) hours of receiving your appeal request. If we extended the time needed to decide your appeal, we will authorize or provide your requested care before the extended time period expires.

Appeal Level 2: Independent Review Entity (IRE)

At the second level of appeal, your appeal is reviewed by an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this entity.

How to file your appeal?

If you asked for Part C medical care or services, or payment for Part C medical care or services, and we did not rule completely in your favor at Appeal Level 1, your appeal is automatically sent to the IRE.

How soon must the IRE decide?

The IRE has the same amount of time to make its decision as the plan had at Appeal Level 1.

If the IRE decides completely in your favor:

The IRE will tell you in writing about its decision and the reasons for it.

For a decision about payment for Part C medical care or services you already received, we must pay within thirty (30) days after we receive notice reversing our decision.
For a standard decision about Part C medical care or services you have not yet received, we must authorize your requested Part C medical care or service within 72 hours, or provide it to you within fourteen (14) days after we receive notice reversing our decision.
For a fast decision about Part C medical care or services, we must authorize or provide your requested Part C medical care or services within seventy-two (72) hours after we receive notice reversing our decision.

Appeal Level 3: Administrative Law Judge (ALJ)

If the IRE does not rule completely in your favor, you or your representative may ask for a review by an Administrative Law Judge (ALJ) if the dollar value of the Part C medical care or service you asked for meets the minimum requirement provided in the IRE’s decision. During the ALJ review, you may present evidence, review the record (by either receiving a copy of the file or accessing the file in person when feasible), and be represented by counsel.

How to file your appeal?

The notice from the IRE will explain how and where to file an appeal with the ALJ. The request must be filed in writing within sixty (60) calendar days of the date you were notified of the decision made by the IRE (Appeal Level 2). You can use the form at the following web address: http://www.cms.hhs.gov/cmsforms/downloads/CMS20034AB.pdf. Or, you can call Member Services at 1-800-927-6048 (TTY/TDD 1-800-828-1120) and we will send this form to you.

The ALJ will not review your appeal if the dollar value of the requested Part C medical care or service does not meet the minimum requirement specified in the IRE's decision. If the dollar value is less than the minimum requirement, you may not appeal any further.

How soon will the Judge make a decision?

The ALJ will hear your case, weigh all of the evidence, and make a decision as soon as possible.

Appeal Level 4: Medicare Appeals Council (MAC)

If the ALJ does not rule completely in your favor, you or your representative may ask for a review by the Medicare Appeals Council (MAC).

How to file your appeal?

The request must be filed with the MAC within sixty (60) calendar days of the date you were notified of the decision made by the ALJ (Appeal Level 3). The MAC may give you more time if you have a good reason for missing the deadline. The decision you receive from the ALJ will tell you how to file this appeal, including who can file it.

How soon will the Council make a decision?

The MAC will first decide whether to review your case (it does not review every case it receives). If the MAC reviews your case, it will make a decision as soon as possible. If it decides not to review your case, you may request a review by a Federal Court Judge (see Appeal Level 5). The MAC will issue a written notice explaining any decision it makes. The notice will tell you how to request a review by a Federal Court Judge.

Appeal Level 5: Federal Court

You have the right to continue your appeal by asking a Federal Court Judge to review your case if the amount involved meets the minimum requirement specified in the Medicare Appeals Council's decision, you received a decision from the Medicare Appeals Council (Appeal Level 4), and:

The decision is not completely favorable to you, or
The decision tells you that the MAC decided not to review your appeal request.

How to file your appeal?

In order to request judicial review of your case, you must file a civil action in a United States district court within sixty (60) calendar days after the date you were notified of the decision made by the Medicare Appeals Council (Appeal Level 4). The letter you get from the Medicare Appeals Council will tell you how to request this review, including who can file the appeal.

Your appeal request will not be reviewed by a Federal Court if the dollar value of the requested Part C medical care or service does not meet the minimum requirement specified in the MAC’s decision.

How soon will the Court make a decision?

The Federal Court Judge will first decide whether to review your case. If it reviews your case, a decision will be made according to the rules established by the Federal judiciary.

If the Court decides against you

You may have further appeal rights in the Federal Courts.

Favorable Decisions by the ALJ, MAC, or a Federal Court Judge

This section explains what we must do if our initial decision denying what you asked for is reversed by the ALJ, MAC, or a Federal Court Judge.

For a decision about Part C medical care or services, we must pay for, authorize, or provide the medical care or service you have asked for within sixty (60) days of the date we receive the decision.

Evidence of Coverage

For more detailed information and a description of the processes, refer to your Evidence of Coverage.

Who to contact about general information or information about the number of Appeals, Grievances and/or Exceptions filed with Optima Medicare?

Optima Medicare (PPO)
Appeals Department
P.O. Box 62876
Virginia Beach, VA 23466-2876
Fax: 757-687-6232 or Toll-free Fax: 1-866-472-3920
Phone: 757-687-6404 or Toll-free Phone: 1-800-927-6048
TTY/TDD: 1-800-828-1120