Sunday, June 5, 2016

What is Expedited Appeals

Expedited Appeals

An expedited appeal is a review of a time-sensitive adverse organization determination or coverage determination that a member believes that he/she is entitled to receive, including:

** Any delay in provding, arranging for, or approving health care services/medications that would adversely affect the health of the member

** Reduction or stoppage of treatment or services that would adversely affect the member’s health

Note: Time-sensitive is defined as a situation in which applying the standard decision time frame could seriously jeopardize a member’s life, health, or ability to regain maximum function.

Members, their representatives, or any treating or prescribing physician (regardless of whether the provider is affiliated with Tufts Medicare Preferred HMO) can request an expedited appeal. Verbal and written requests for expedited appeals are accepted. If the request meets the necessary time-sensitive criteria, a decision will be made within 72-hours of receipt of the request, unless an extension is needed. Extensions of up to 14 calendar days can be granted if in the best interest of the member.

Note: Extensions are not allowed for expedited Part D appeals.

Independent Review Entity (IRE) Review and Additional Appeal Levels

1. MAXIMUS Federal Services, Inc. is the Independent Review Entity (IRE) that reviews the information provided by Tufts Health Plan Medicare Preferred and requests any additional documentation needed from either Tufts Health Plan Medicare Preferred or the member. MAXIMUS Federal Services, Inc. is a separate entity from the QIO, which (in this area) is Livanta.

2. MAXIMUS Federal Services, Inc.’s reconsideration determination is final and binding, unless a request for a hearing before an Administrative Law Judge (ALJ) is filed within 60 calendar days of receiving the reconsideration notice.

3. Any member, including Tufts Medicare Preferred HMO, can request a judicial review (after notifying other parties) of an ALJ decision, if the amount in controversy meets the appropriate threshold (new thresholds are published by CMS every fall) and the Medicare Appeals Council (MAC) denied the member's request for review.

4. Any decision by Tufts Health Plan Medicare Preferred, MAXIMUS Federal Services, Inc., the ALJ, or the MAC can be reopened within 12 months or within 4 years for good cause. Once a revised determination or decision is issued, any party can file an appeal.

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