How to obtain An Organization Determination (Coverage decision)
Medical - Organization Determination –
An Organization Determination is a coverage decision for Medical Care. CareFirst Medicare Advantage has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. CareFirst Medicare Advantage’s network provider or facility has also made an organization determination when it provides you with an item or service, or refers you to an out-of-network provider for an item or service. Organization determinations may also be called “coverage decisions”.
Here is how to request coverage for the medical care you want
- Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this.
- Our contact information (phone number, address, and fax number) is available to you on the Contact Us page of this website and in our Evidence of Coverage (EOC). You can also call us using the number on the back of your id card.
Additional information regarding requesting an Organization Determination is provided in the EOC.
Medical - Appeal rights
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
There are two kinds of appeals you can request:
- Expedited (72 hours) - You can request an expedited (fast) appeal for cases that involve medical coverage determinations if you or your doctor believes that your health could be seriously harmed by waiting up to 30 days for a decision. If your request to expedite is granted, we must make a decision no later than 72 hours after receiving your appeal.
- Standard (30 - 60 days) - You can request a standard appeal for a case that involves medical coverage or payment determinations. We must give you a decision no later than 30 days after receiving your appeal for coverage appeals or 60 days for claims payment appeals.
What Do I Include with My Appeal?
You should include your name, address, and Member ID number. You should also include the reasons for your appeal, and any evidence you wish to attach.
How Do I Request an Appeal?
To start an appeal, you, your doctor, or your representative must contact us.
For an Expedited Appeal: We suggest contacting us by telephone or submit your request by fax. Be sure to ask for a "fast or expedited review." This means you are asking us to give you an answer using the expedited deadlines rather than the standard deadlines.
For a Standard Appeal: Make your standard appeal in writing by submitting a request. Standard appeals must be in writing. Please send your appeal to us at the address below.
Appeals & Grievances Department
PO Box 915
Owings Mills, MD 21117
Fax: 1-844-405-2158
For more information about your appeal rights, call Member Services at the number located on the back of your ID card, refer to the Evidence of Coverage, or visit the Contact Us page of this website.
Medicare Non Participating Provider Appeal Rights
Payment Appeals Submission Requirements and Review Process:
If the non-contracted Medicare health plan provider disagrees with a claim payment denial, they have 60 calendar days from the initial organization determination date to file a written payment appeal.
A written request for a payment appeal along with any supporting documentation and a completed Waiver of Liability form must be sent to Appeals & Grievances Mailing Address:
CareFirst BlueCross BlueShield Medicare Advantage
Appeals & Grievances Department
PO Box 915
Owings Mills, MD 21117
Upon receipt of a valid request for a payment appeal, the plan has 60 calendar days to review and respond. Note that in order to be considered a valid payment appeal, the request must include a completed and signed Waiver of Liability (WOL) form. If the WOL is not submitted or complete, the plan will dismiss your request.
Waiver of Liability (WOL) Form
If CareFirst Medicare Advantage upholds the initial determination in whole or in part, the plan must forward the case to CMS’ Independent Review Entity (IRE) for a second level review. The current IRE for payment appeals is Maximus Federal Services. The IRE will review the case and send a resolution to the provider and the plan
GRIEVANCES
The grievance process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the grievance process.
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Grievance
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Example
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Quality of your medical care
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- Are you unhappy with the quality of the care you have received (including care in the hospital)?
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Respecting your privacy
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- Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?
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Disrespect, poor customer service, or other negative behaviors
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- Has someone been rude or disrespectful to you?
- Are you unhappy with how our Member Services has treated you?
- Do you feel you are being encouraged to leave the plan?
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Waiting times
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- Are you having trouble getting an appointment, or waiting too long to get it?
- Have you been kept waiting too long by doctors, pharmacists, or other health professionals? Or by our Member Services or other staff at the plan?
- Examples include waiting too long on the phone, in the waiting room, when getting a prescription, or in the exam room.
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Cleanliness
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- Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor’s office?
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Information you get from us
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- Do you believe we have not given you a notice that we are required to give?
- Do you think written information we have given you is hard to understand?
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Timeliness
(These types of grievances are all related to the timeliness of our actions related to coverage decisions and appeals)
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If you are asking for a decision or making an appeal, you use that process, not the grievance process. However, if you have already asked us for a coverage decision or made an appeal, and you think that we are not responding quickly enough, you can also make a grievance about our slowness. Here are examples:
- If you have asked us to give you a “fast coverage decision” or a “fast appeal, and we have said we will not, you can make a grievance.
- If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a grievance.
- When a coverage decision we made is reviewed and we are told that we must cover or reimburse you for certain medical services or drugs, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a grievance.
- When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a grievance.
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To file a grievance you can do the following:
- Usually, calling Member Services is the first step. You can call Member Services at the number located on the back of your ID card, refer to the Evidence of Coverage, or visit the Contact Us page of this website.
- If you do not wish to call (or you called and were not satisfied), you can put your grievance in writing and send it to us. If you put your grievance in writing, we will respond to your grievance in writing. Submit your written grievance to us at:
CareFirst BlueCross BlueShield Medicare Advantage
Attention: Appeals & Grievance Department
PO Box 915
Owings Mills, MD 21117
The grievance must be submitted within 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 30 days after receiving your grievance. We may extend the time frame by up to 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 do not accept your grievance in the whole or in part, our written decision will explain why it was not accepted, and will tell you about any dispute resolution options you may have.
Whether you call or write, you should contact Member Services right away. The grievance must be made within 60 calendar days after you had the problem you want to complain about.
If you are making a grievance because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” grievance. If you have a “fast” grievance, it means we will give you an answer within 24 hours.
Medical Policies and Determinations
CareFirst Medical Policy Guidelines describe when certain medical services are considered medically necessary and are based on Original Medicare National Coverage Determinations (NCD's) and Local Coverage Determinations (LCD's) when available. Where no NCDs or LCDs exist, CareFirst BlueCross BlueShield Medicare Advantage will apply industry standard and CareFirst medical policies.