Who can submit an appeal?

You, your authorized representative or your doctor can submit an appeal to Virginia Premier.

This is a summary about the procedures and contact information for Coverage Decisions, Complaints, Appeals & Grievances with Virginia Premier CompleteCare (Medicare-Medicaid Plan). Complete information about Coverage Decisions, Complaints, Appeals and Grievances can be found in Chapter 9 of the Member Handbook, which can be found on the Plan Documents page.




Coverage Decisions

A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay.If you or your doctor are not sure if a service, item, or drug is covered by Medicare or Medicaid, either of you can ask for a coverage decision before the doctor gives the service, item, or drug.Sometimes a coverage decision is also called an organization determination.

How can I file a coverage decision to get a medical, behavioral health or long-term care service?

To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a decision.

  • You can call us at: 1-855-338-6467 TTY/TDD: 1-800-828-1120 or 1-800-828-1140
  • You can fax us at: 1-877-739-1364
  • You can to write us at:
CompleteCare Medical Management
PO box 4388
Richmond, VA 23220

How long does it take to get a coverage decision?

It usually takes up to 14 calendar days after you asked. If we don’t give you our decision within 14 calendar days, you can appeal. Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days.

Can I get a coverage decision faster?

Yes. If you need a response faster because of your health, you should ask us to make a “fast coverage decision.” If we approve the request, we will notify you of our decision within 72 hours.

Asking for a fast coverage decision:

If you request a fast coverage decision, start by calling, writing, or faxing our plan to ask us to cover the care you want. You can call us at 1-855-338-6467. You can also have your doctor or your representative call us.

Here are the rules for asking for a fast coverage decision:

You must meet the following two requirements to get a fast coverage decision:

  • You can get a fast coverage decision only if you are asking for coverage for medical care or an item you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care or an item you have already received.)
  • You can get a fast coverage decision only if the standard 14-day deadline could cause serious harm to your health or hurt your ability to function.
If your doctor says that you need a fast coverage decision, we will automatically give you one.

If you ask for a fast coverage decision, without your doctor’s support, we will decide if you get a fast coverage decision. Please see Chapter 9 of the Member Handbook for additional information.

If the coverage decision is Yes, when will I get the service or item?

You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period.

If the coverage decision is No, how will I find out?

If the answer is No, we will send you a letter telling you our reasons for saying No.

If we say no, you have the right to ask us to reconsider – and change – this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage.

If you decide to make an appeal, it means you are going on to Level 1 of the appeals process.

How can I file a coverage decision for a Part D drug?

Call us or send us a Medicare Prescription Drug Determination Request Form, which can be found on our Plan Documents page. You, your representative, or your doctor (or other prescriber) can do this.
  • You can call us at: 1-855-338-6467 TTY/TDD: 1-800-828-1120/1-800-828-1140
  • You can fax us at: 1-877-739-1364
  • You can to write us at:

CompleteCare Medical Management
PO box 4388
Richmond, VA 23220

If you are requesting an exception, provide the “supporting statement.” Your doctor or other prescriber must give us the medical reasons for the drug exception. We call this the “supporting statement.”

Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement.

If you want to ask us to pay you back for a drug, see Chapter 7 of the Member Handbook. It describes the timeline and the needed paperwork that asks us to pay you back for our share of the cost of a drug you have paid for.  You can download a Member Reimbursement form for drugs on our Plan Documents page.

How long does it take to get a coverage decision for Part D drugs?

We will give you an answer on a standard coverage decision within 72 hours. We will give you an answer on reimbursing you for a Part D drug you already paid for within 14 calendar days.

  • If you are asking for an exception, include the supporting statement from the doctor or other prescriber.
  • You or your doctor or other prescriber may ask for a fast decision. (Fast decisions usually come within 24 hours.) Please see Chapter 9, Section 6 of the Member Handbook for more information.

Appeals

An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagree with our decision, you can appeal.

How do I file an appeal?

To start your appeal, you, your doctor or other provider, or your representative must contact us in writing or by phone.  You can download a Grievance and Appeals form on our Plan Documents page (under “Forms”).

You can submit a request to the following address:

Virginia Premier Health Plan, Inc.
Attn: Grievance & Appeals
PO Box 5244
Richmond, VA 23220

Or by faxing a written request to: 804-649-9647.  You may also ask for an appeal by calling us at 1-855-338-6467.

Can someone else make the appeal for me?

Yes. Your doctor or other provider can make the appeal for you. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative form. The form gives the other person permission to act for you.

To get an Appointment of Representative form, call Member Services and ask for one, or visit the Medicare website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf, or look on the Plan Documents page (under “Forms”). The form will give the person permission to act for you. You must give us a copy of the signed form.

If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal.

How much time do I have to make an appeal?

You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of a good reason are: you had a serious illness, or we gave you the wrong information about the deadline for requesting an appeal.

Can my doctor give you more information about my appeal?

Yes, you and your doctor may give us more information to support your appeal.

When will I hear about a “standard” appeal decision?

If your appeal is about:

  • A Part D drug — You’ll get a decision in 7 calendar days.
  • A non-Part D drug, a Medicare-covered service, or a Medicaid-covered service — You’ll get a decision in 30 calendar days. We can also take up to 14 extra calendar days if we need more information.
When will I hear about a “fast” appeal decision?

If your appeal is about:

  • A Part D drug — You’ll get a decision in 24 hours.
  • A non-Part D drug, a Medicare-covered service, or a Medicaid-covered service — You’ll get a decision in 72 hours.  We will give you our answer sooner if your health requires us to do so.  However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter.
If the answer is Yes

If our answer is yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal.

If the answer is No

If our answer is no to part or all of what you asked for, we will send you a letter. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens. Or you can see Chapter 9 of the Member Handbook for more information.

Grievances (Complaints)

A grievance is a type of complaint that does not involve payment, denial or discontinuation of services by Virginia Premier CompleteCare or a network provider. For example, you would file a grievance if:

  • You are unhappy with the quality of care, such as the care you got in the hospital.
  • You think that someone did not respect your right to privacy, or shared information about you that is confidential.
  • A health care provider or staff was rude or disrespectful to you.
  • Virginia Premier CompleteCare staff treated you poorly.
  • You think you are being pushed out of the plan.
  • You cannot physically access the health care services and facilities in a doctor or provider’s office.
  • You are having trouble getting an appointment, or waiting too long to get it.
  • You think the clinic, hospital or doctor’s office is not clean
  • Your doctor or provider does not provide you with an interpreter during your appointment.
  • You think we failed to give you a notice or letter that you should have received.
  • You believe that we are not meeting our deadlines for making a coverage decision or answering your appeal.
How to file a complaint (grievance)

Call Member Services at 1-855-338-6467. The complaint must be made within 60 calendar days after you had the problem you want to complain about. If there is anything else you need to do, Member Services will tell you.

You can also write your complaint and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.   You can download a Grievance and Appeals form on our Plan Documents page   (under “Forms”).

Virginia Premier Health Plan, Inc.
Attn: Grievance & Appeals
PO Box 5244
Richmond, VA 23220

Grievances and Appeals Fax Number: 804-649-9647

If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast complaint” and respond to your complaint within 24 hours.

If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.

  • Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest, or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.
  • If we do not agree with some or all of your complaint we will tell you and give you our reasons. We will respond whether we agree with the complaint or not.
You can tell Medicare about your complaint

You can also send your complaint to Medicare. The Medicare Complaint Form is available at https://www.medicare.gov/MedicareComplaintForm/home.aspx

Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.

If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. The call is free.

If help is needed

You can ask any of these people for help regarding coverage decisions or making an appeal:
  • You can call us at Member Services at 1-855-338-6467.
  • Call the Office of the Managed Care Ombudsman for free help. The Office of the Managed Care Ombudsman helps people enrolled in a managed care health plan. The phone number is 1-877-310-6560.
  • Call the Office of the State Long-Term Care Ombudsman for free help. The Office of the State Long-Term Care Ombudsman helps people receiving long-term care services. The phone number is 1-800-552-3402.
  • Call the Medicare Ombudsman at 1-800-MEDICARE or visit the website.
  • Call the Virginia Insurance Counseling and Assistance Program (VICAP) for free help. The VICAP is an independent organization. It is not connected with this plan. The phone number is 1-800-552-3402.
  • If you feel you have used all your options with us, you may submit a Medicare complaint form at Medicare.gov.
  • Talk to your doctor or other provider. Your doctor or other provider can ask for a coverage decision or appeal on your behalf.
  • Talk to a friend or family member and ask him or her to act for you. You can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.
  • If you want a friend, relative, or other person to be your representative, call Member Services and ask for the “Appointment of Representative” form. You can also get the form on the Medicare website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf, or on the Plan Documents page (under “Forms”). The form will give the person permission to act for you. You must give us a copy of the signed form.
  • You also have the right to ask a lawyer to act for you. You may call your own lawyer, or get the name of a lawyer from the local bar association or other referral service. Some legal groups will give you free legal services if you qualify. If you want a lawyer to represent you, you will need to fill out the Appointment of Representative form.
  • However, you do not have to have a lawyer to ask for any kind of coverage decision or to make an appeal.

How can I get a total number of grievances, appeals and exceptions filed with Virginia Premier CompleteCare?

Please call us at 1-855-338-6467.

For process or status questions about a coverage decision, appeal or grievance

Please call us at 1-855-338-6467.

Have Questions? Let’s talk.

Call us at 1-855-338-6467, 8:00 a.m. to 8:00 p.m., Monday through Friday. For TTY/TDD services, please call 1-800-828-1120 (Text), 1-800-828-1140 (Voice). The call is free.

 

Additional Information

Virginia Premier CompleteCare is a health plan that contracts with both Medicare and the Virginia Department of Medical Assistance Services to provide benefits of both programs to enrollees.

You can get this information for free in other languages. Call 1-855-338-6467, 8:00 a.m. to 8:00 p.m., Monday through Friday. For TTY/TDD services, please call 1-800-828-1120 (Text), 1-800-828-1140 (Voice). The call is free.

You can ask for this information in other formats, such as Braille or large print. Call 1-855-338-6467, 8:00 a.m. to 8:00 p.m., Monday through Friday. For TTY/TDD services, please call 1-800-828-1120 (Text), 1-800-828-1140 (Voice).

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