Virginia Premier Health Plan, Inc.

Grievances/Complaints/Appeals

Member Grievances/Complaints

Virginia Premier Health Plan, Inc. (VPHP) and its doctors and hospitals are dedicated to your health and well-being. Our Member Services Department is available to assist you with any questions or concerns. If you have a problem that has not been resolved, let us know. VPHP will make every effort to solve the issue in a satisfactory way. Your inquiries and grievances are important to us. A Member Services Representative can assist you with your concerns about:

• Difficulty in getting a doctor's appointment
• Your treatment as a VPHP Member
• Your medical care or treatment by your doctor
• Payment of medical bills
• Medicaid Fraud and Abuse
• You do not agree with our decision not to approve care

Grievances are when you call or send a letter to VPHP to tell us you are not happy with a certain part of your:

• Benefits
• Quality of care
• Access to health care services
• Failure to respect your rights
• Payment and reimbursement issues
• Administrative issues
• Services provided

Types of Grievances

• Grievance: An expression of dissatisfaction about any matter other than an "action." Possible subjects for grievances include, but are not limited to, the quality of care or services provided and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member's rights.
• Quality of Care Grievance: An expression of dissatisfaction regarding the caliber of medical treatment rendered by a provider.
• Quality of Service Grievance: An expression of dissatisfaction regarding how the member felt he/she was treated as a person. Also includes dissatisfaction related to lack of access to care

Virginia Premier Health Plan, Inc. will respond to your grievance within thirty (30) days of the date of the initial receipt or sooner if the condition warrants a quicker response. Grievances may be extended up to fourteen (14) calendar days if the member or provider requests such extension or if the health plan shows (to the satisfaction of the State agency – DMAS, upon its request) that there is a need for additional information and how the delay is in the member’s best interest. The written notice must be mailed no later than the 14th day to the member and must describe the reason for the decision to extend the timeframe and informing the member of the right to file a grievance if he or she disagrees with that decision. The review will be completed for final determination as expeditiously as the member’s health condition allows and shall not exceed the date on which the extension expires.

If you do not agree with the decision made by Virginia Premier Health Plan, Inc., you can get in touch with VPHP’s Member Services Department by calling:

Phone #: (800) 289-4970
TTY (800) 828-1120
TDD (800) 828-1140

or

Write us at the address listed below:

Virginia Premier Health Plan, Inc.
Medical Management Grievances and Appeals Office
P.O. Box 5244
Richmond, VA 23220-0244
Fax Number – (804) 819-5186

Member Appeals or Appeals filed on Behalf of a Member

If you are not happy with the answer given to you by VPHP concerning your grievance or other action, you or another person (i.e., practitioner/provider, legal representative, etc.) authorized by you can file an appeal within thirty (30) days of receiving VPHP’s response. The member’s benefits will automatically continue, without any action from the member, throughout the appeal process including the period during which and when the State Fair Hearing is pending if all of the following criteria are met:

• The member or the practitioner/provider, on behalf of the member, files the appeal within ten (10) days of the date on which VPHP’s mailed the notice of adverse action or prior to the effective date of VPHP’s notice of adverse action; and
• The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; and
• The services were ordered by an authorized provider; and
• The original period covered by the initial authorization has not expired; and
• The member requests extension of benefits.

Members: To file an appeal or request assistance with filing an appeal, contact:

Virginia Premier Health Plan, Inc.
Member Services Department
Phone #: (800) 289-4970
TTY (800) 828-1120
TDD 800-828-1140

When filing a request for an appeal, please be sure to always include the following information in, or with your cover letter:

• The denial decision you are appealing
• Your Complete Mailing Address
• Member's Medicaid I.D. Number
• Member's Name
• Reference/Referral Number (if applicable)
• A copy of the denial letter that prompted your decision to appeal
• All supporting documentation that your feel will help to reverse Virginia Premier's decision
• Your Phone Number (including area code)

When filing a request for an appeal, please be sure to utilize the correct address for the type of appeal you are filing (see below). Sending your appeal request to the appropriate address, along with the information listed above, will help to expedite the processing of your appeal request.

Types of Appeals

Practitioners/Providers: To file an appeal, on behalf of a member, or request assistance with filing an appeal, contact:

Clinical Appeals

• Lack of Medical Necessity
  
  Mailing Address for Clinical Appeals:
  Virginia Premier Health Plan, Inc.
  Medical Management Grievances and Appeals Office
  Attn: Grievances and Appeals Manager
  P.O. Box 5244
  Richmond, VA 23220-0244
  Fax Number – (804) 819-5186

Claim Appeals

• Timely Filing Issues
• Reimbursement Issues
• Failure to Verify Eligibility
• Requests for Retro-Authorizations (failure to obtain pre-authorization)
• Duplicate Claims
• Non-Covered Services
• Retro Referral Requests (failure to obtain a referral)
  
  Mailing Address for Claim Appeals:
  Virginia Premier Health Plan, Inc.
  Attn: Claims Appeals
  Richmond, VA 23220-0286
  Fax Number – (804) 819-5174

Credentialing Appeals

• Expired State License Discrepancies
• Expired Malpractice Insurance Discrepancies
• Denial From VPHP's Provider Network
  
  Mailing Address for Credentialing Appeals:
  Virginia Premier Health Plan, Inc.
  Medical Management Grievances and Appeals Office
  P.O. Box 5244
  Richmond, VA 23220-0244
  Fax Number – (804) 819-5186

Additional Member Appeal Rights

You or your authorized representative may also submit a request for an expedited or standard State fair hearing directly to the Department of Medical Assistance Services (DMAS).

FAMIS and Medallion II Members may submit a request for a State Fair Hearing to DMAS at the same time that an appeal is submitted to Virginia Premier; or, after exhausting the Virginia Premier appeal’s process; or, instead of appealing to Virginia Premier. State fair hearing requests must be submitted to DMAS in writing.
You or your authorized representative may write a letter or complete an Appeal Request Form. Forms are available on the Internet at www.dmas.virginia.gov, the local Department of Social Services, or by calling 807-371-8488. Written requests to DMAS must be sent within 30 days of the date of the grievance response to:

Department of Medical Assistance Services
Appeals Division
600 East Broad Street
Richmond, Virginia 23219
(804) 371-8488

Virginia Premier Health Plan, Inc. offers two types of Appeals

Expedited Appeal

An Expedited Appeal may be requested over the telephone when your provider determines that the standard appeals timeframe could jeopardize your life or health, ability to attain, maintain or regain maximum function. Telephone or fax the request to the numbers listed below. A written appeal is not necessary for expedited appeals. Once the request is received, Virginia Premier Health Plan, Inc. and/or the Department of Medical Assistance Services will select an appeal physician of the same or similar specialty as typically manages the condition, procedure or treatment in question, that was not involved in the initial denial of services. Decisions for expedited appeals will not take more than three (3) days from the initial receipt of the appeal.

Standard Appeal

Standard Appeals are generally made after the services have been rendered or completed and may be requested telephonically or in writing. All verbal appeal requests must be followed by a written appeal request. You may obtain a copy of the appeals form by calling Member Services and requesting one. You or your representative may request an in person interview to present additional evidence and allegations of fact or law within five (5) days of filing an appeal. All appeals will be resolved within 30 days.

You may also address complaints or concerns about suspected Medicaid fraud or abuse to the following:

State Corporation Commission
Bureau of Insurance
P. O. Box 1157
Richmond, Virginia 23218
Toll-Free:  (800) 552-7945
Local:  (804) 371-9741
http://www.scc.virginia.gov/division/boi/webpages/boifilecomplaint.htm
http://www.scc.virginia.gov/division/boi/webpages/boiombudmanmchipinquiry.htm

Virginia Department of Health Professions
Perimeter Center
9960 Mayland Drive, Suite 300
Richmond, Virginia 23233
Toll-Free:  (800) 533-1560
Local:  (804) 367-4400
Fax:  (804) 527-4475
http://www.dhp.virginia.gov/Enforcement/complaints.htm

Virginia Department of Health
Center for Quality Health Care Services and Consumer Protection
Complaint Division                                           
3600 West Broad Street – Suite 216
Richmond, Virginia 23230
Toll-Free:  (800) 955-1819
Fax:  (804) 367-2149
http://www.vdh.state.va.us/OLC/AcuteCare/mchip.htm
http://www.vdh.state.va.us/OLC/Forms/documents/MCHIP/MCHIP_enrollee_Complaint_Form.doc

Virginia Premier Health Plan, Inc.
Attn: Office of Privacy & Compliance
600 East Broad Street, Suite 400
Richmond, Virginia 23219-1800
https://www.compliance-helpline.com/welcomePageVCUHS.jsp
VPHP toll-free, anonymous, 24 hours Compliance Help Line #: (800) 620-1438

All claims or grievances of any nature against the Virginia Premier Health Plan, Inc., its employees, agents, board members, or officers whether filed by a member or a spouse or personal representative of a member, should go through the Grievance and Appeals Procedures discussed above before any action or proceeding may be sought out.

Virginia Premier Health Plan's, Inc. policy is to respond promptly to inquiries, grievances and appeals through all stages of the process. For a copy of Virginia Premier Health Plan's, Inc. complete policy and process, call Virginia Premier Health Plan, Inc. Member Services Department.

For questions regarding your Medicaid eligibility call DSS.

Virginia Premier Health Plan, Inc. is subject to regulations in this Commonwealth by the State Corporation Commission Bureau of Insurance pursuant to Title 38.2 and by the Virginia Department of Health pursuant to Title 32.1.