APPEALS
You can file an appeal if Mercy Care Advantage (MCA) will not pay for, does not allow, or stops a service that you think should be covered or provided. In addition, you can challenge the exclusion of a drug from MCA's formulary or the placement of a drug on a higher cost sharing tier. Each of these options is described below.
If you need an interpreter, one can be provided at no cost to you.
Service Related
When you or your representative make an authorization request for service, MCA will notify you of a determination by mail within 14 days of your request. If the determination is unfavorable, you may have a right to appeal.
Healthcare service providers may bill MCA for benefits that you receive. Each service you receive is considered a "claim". Claims are paid based on the information the provider supplies and your benefits as a Mercy Care Advantage member. When payment for a claim is denied, you will have the right to appeal.
As a Mercy Care Advantage member, you have the right to file an appeal under any of the following conditions:
- MCA denied payment for temporarily out of the area renal dialysis services
- MCA denied payment for emergency services, post-stabilization care or urgently needed services
- MCA denied payment for any other health services furnished by a provider
- MCA refused to authorize, provide or pay for services, in whole or in part
- MCA discontinued a service
- MCA failed to approve, furnish, arrange for, or provide payment for health care services in a timely manner
Once you receive a notification for any of the conditions listed above, you can file an appeal within 60 days from the date of the notification letter. You or your representative can telephone or write Mercy Care Advantage to file an appeal. If you think your health could be seriously harmed by waiting for a decision about a service, ask MCA if you qualify for a fast (expedited) decision.
There are five levels to the appeals process for denied services and non-payment of claims:
| |
DESCRIPTION |
STANDARD APPEAL |
EXPEDITED APPEAL |
| 1 |
Reconsideration by MCA |
Upon receipt of your appeal, the Appeals Department sends you an acknowledgement letter to confirm the facts and basis of the appeal.
Your appeals is evaluated by the Appeals Department and a clinical expert if necessary.
A decision letter is sent to you within 30 days of receipt for service requests and 60 days of receipt for payment requests.
|
Only for service requests.
An appeal representative will notify you of the decision within 72 hours after receiving your appeal or sooner depending on your condition.
|
| 2 |
Reconsideration by Independent Review Entity (IRE) |
If MCA denies (in whole or in part) your appeal request, your file is automatically forwarded
for reconsideration by the IRE within the timeframes listed above. The IRE will review your appeal and make a
decision within 30 days for service requests and 60 days for payment requests. |
If MCA denies your expedited appeal (in whole or in part), your file is forwarded within 24 hours for reconsideration by the IRE. |
| 3 |
Administrative Law Judge (ALJ) |
If the IRE decision is unfavorable and the amount in dispute is at least $110,
you may request a hearing with the ALJ. You must follow the instructions on the notice from the IRE. |
Not available |
| 4 |
Medicare Appeals Council (MAC) |
If the ALJ decision is unfavorable, you may appeal to the MAC, which is within
the Department of Health and Human Services, which reviews ALJ's decisions. |
Not available |
| 5 |
Judicial Review |
If the MAC denied your request for appeal, and the amount in dispute
meets the minimum required, you may request judicial review of the ALJ decision. If the MAC decision is
unfavorable, and the amount in controversy meets at least the minimum $1,130 dollar requirement, you may
request judicial review of the MAC decision.
You must file a civil action in a district court to request a judicial review. Refer to the MAC decision notice for more information.
|
Not available |
Prescription Drugs
Giving you the best care possible is important to Mercy Care Advantage (MCA), so we have designed a process for prescription drugs with you in mind. The coverage determination and appeals process provides you with the opportunity to challenge the exclusion of a drug from the formulary or the placement of a drug on a higher cost sharing tier. You receive a notice from your pharmacist explaining how you can obtain a coverage determination or request an exception.
The exception process, which makes sure that you have access to prescription drugs you need, is unique to the prescription drug benefit. It provides a straightforward process for you to obtain a covered drug at a more favorable cost sharing level or obtain a drug that is not on the formulary.
You may request an exception under any of the following circumstances:
- You are using a drug covered on the formulary that has been removed during the plan year for reasons
other than safety
- Your doctor prescribed a drug that is not on the formulary because it is medically necessary
- You are using a drug that has been moved during the plan year from the preferred to the non-preferred
cost sharing tier
- Your doctor prescribed a drug that is in the more expensive cost sharing tier because the drug in
the less expensive cost sharing tier is medically inappropriate for you
If MCA makes an unfavorable coverage determination or denies your exception request, you or your representative may appeal
the decision within 60 days from the date of the coverage determination notice. If you need more information
about filing an appeal, refer to the instructions on your coverage determination notice or contact an
MCA appeals representative.
The coverage determination and appeals process for prescription drugs consists of the following:
| |
DESCRIPTION |
STANDARD |
EXPEDITED* |
| 1 |
Coverage determination and exception request by MCA |
Upon receipt of a coverage determination request, MCA will notify you of a decision within 72 hours.
Upon receipt of your doctor's supporting statement for an exception request, MCA will notify you of a decision within 72 hours.
|
Same as standard, except the timeframe is 24 hours for you to be notified of a decision.
If you were informed of the decision verbally, you will be sent a confirmation letter describing the decision within 3 days.
|
| 2 |
Redetermination by MCA |
If the initial coverage determination or exception request if unfavorable, you may request a redetermination by MCA.
Upon receipt of an appeal, the Appeals Department sends you an acknowledgement letter to confirm the facts and basis of the appeal.
Your appeal is evaluated by the Appeals Department and a clinical expert if necessary.
A decision letter is sent to you within 7 days.
|
Same as standard except the timeframe is 72 hours for an appeal representative to make a decision |
| 3 |
Reconsideration by Independent Review Entity (IRE) |
If the redetermination is unfavorable, you may request a
reconsideration by the IRE within 60 days of the date of the redetermination letter. |
Your expedited request will be forwarded to the IRE within 24 hours. |
| 4 |
Administrative Law Judge (ALJ) |
If the RIE decision is unfavorable, and the amount in controversy meets at
least the minimum $110 dollar requirement, you may request a hearing with an ALJ.
This must be filed in writing within 60 days to the date of the notice sent by the IRE.
Refer to this notice for more information.
|
Not available |
| 5 |
Medicare Appeals Council (MAC) |
If the ALJ decision is unfavorable, you may appeal to the MAC,
which is within the Department of Health and Human Services, which reviews ALJ's decisions.
|
Not available |
| 6 |
Judicial Review |
If the MAC denied your request for appeal, and the amount in dispute meets the minimum required, you may request judicial review of the ALJ decision.
If the MAC decision is unfavorable, and the amount in controversy meets at least the minimum dollar requirement of $1,130 you may request judicial review of the MAC decision.
You must file a civil action in a district court to request a judicial review. Refer to the MAC decision notice for more information.
|
Not available |
* An expedited decision is requested based on the urgency of your health condition.
Contact Information:
Telephone:
Local: (602) 263.3000
Toll Free: (800) 624-3879
Expedited (Fast) Appeals (602) 351-2314 M-F 8a.m.- 5p.m., S 7a.m.- 5p.m.
Fax: (602) 351-2300
TTY/TDD
Toll Free: (866) 602-1982 M-F 7a.m.-6p.m.
(602) 454-9208 all other times
Mercy Care Advantage Mailing Address:
Mercy Care Advantage
Appeals Department
4350 E Cotton Center Blvd.
Bldg. D
Phoenix, Arizona 85040
Medicare Appeals Council Mailing Address:
Department of Health and Human Services
Departmental Appeals Board, MS 6127
Medicare Appeals Council
330 Independence Avenue, S.W.
Cohen Building, Room G-644
Washington, DC 20201