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Friday, June 3, 2016

Standard member appeal for part c and part d services



Standard Member Appeals

In most cases the organization determination and coverage determinations are final unless a member contacts Tufts Health Plan Medicare Preferred within 60 calendar days of receiving the determination, (or longer if there is a reason for a good cause extension). If a member requests reconsideration (appeal) of a denial, we follow the Standard Member Appeals Procedure below. The appeal procedure takes place after the adverse organization determination has been issued by the Plan.



Standard Member Appeals Procedure for Part C Services

1. The member sends a written request for reconsideration to the Tufts Health Plan Medicare Preferred Appeals and Grievances department. For pre-service and post-services requests, the treating provider may also request an appeal in writing without being appointed as the member's representative as long as the provider notifies the member the provider is filing the appeal.

** The Tufts Health Plan Medicare Preferred Appeals and Grievances department receives and reviews the written appeal and, if needed, will request additional documentation.

** The member can identify an Appointment of Representative (AOR) as an authorized representative to act on their behalf during the appeal process.

Note: If the member does have an AOR or activated Health Care Proxy, all correspondence regarding the appeal must be sent to the AOR instead of the member.

** The Appeals and Grievances department consults with other Tufts Health Plan Medicare Preferred departments when appropriate, and completes the investigation and notifies the member as expeditiously as the member’s health condition requires, not exceeding 30 calendar days for pre-service requests and not exceeding 60 calendar days for post-service requests from the date the reconsideration request was received (or no later than upon expiration of a 14 calendar-day extension), regardless of whether or not the organization determination was overturned.

2. Tufts Health Plan Medicare Preferred can extend a service review time frame up to 14 calendar days, but only if the extension is requested by the member or if Tufts Health Plan Medicare Preferred determines that additional information is necessary and the delay is in the best interest of the member, such as for additional diagnostic testing or consultation with medical specialists. Lack of availability of plan provider medical records is not an acceptable reason for delay.

3. If the organization determination was not overturned, the notice informs the member that all relevant information was forwarded to the CMS reconsideration contractor, MAXIMUS Federal Services, Inc. (Forwarding an appeal to Maximus does not apply to Medicaid-only members)


Standard Member Appeals Procedure for Part D Services


1. The member sends a written request for redetermination to the Appeals and Grievances department. For pre-service requests, the prescribing provider may also submit a written request to request an appeal without being appointed as the member's representative as long as the provider notifies the member that he/she is filing the appeal on the member’s behalf.

** The Appeals and Grievances department receives and reviews the written appeal and, if needed, will request additional documentation.

** The member can identify an AOR to act on their behalf during the appeal process.

Note: If the member does have an AOR or activated Health Care Proxy, all correspondence regarding the appeal must be sent to the AOR instead of the member.

** The Appeals and Grievances department consults with other Tufts Health Medicare Preferred departments when appropriate, and completes the investigation as expeditiously as the  member’s health condition requires, not exceeding 7 calendar days from the date the redetermination request was received.

2. Tufts Health Plan Medicare Preferred may not extend the review timeframe beyond 7 calendar days for Part D appeals.

3. The member/AOR receives written notice within 7 calendar days, regardless of whether or not the coverage determination was overturned.

4. If the coverage determination was not overturned, the notice informs the member of the right to submit a reconsideration request to MAXIMUS Federal Services, Inc. Included with the decision notice is a Request for Reconsideration notice for the member to send to the MAXIMUS Federal Services, Inc.

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