Organization Determination (Medical Coverage Decision)
An Organization Determination is a coverage decision for Medical Care.
When Alterwood Advantage makes a decision about whether healthcare items or services are covered or how much you have to pay for covered healthcare items or services, this is an organization determination. Alterwood Advantage network provider or facility also makes an organization determination when providing you with a healthcare item or service or refers you to an out-of-network provider for a healthcare item or service. Organization determinations may also be called “coverage decisions”.
How to request coverage for the medical care you want:
- You, your doctor, or your representative can call, write, or fax Alterwood Advantage to request that we authorize or provide coverage for the medical care you want.
- Our contact information (phone number, address, and fax number) is available to you on the About Us – Contact Us page of this website or refer to the Evidence of Coverage in the Member Resources page of this website. You can also call Member Services using the number on the back of your ID card: 667-262-9412 or 866-675-3944, TTY/TDD 711, or email MemberServices@AlterwoodHealth.com
- The Evidence of Coverage in the Member Resources page of this website also provides additional information about requesting an Organization Determination (coverage decision).
Appeals
Medical – Appeal Rights
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
There are two kinds of appeals you can request:
- Expedited (72 hours)– You can request an expedited (fast) appeal for cases that involve medical coverage determinations if you and your doctor believe that your health could be seriously harmed by waiting up to 30 calendar days for a decision. If your request to expedite is granted, we must make a decision no later than 72 hours after receiving your appeal.
- Standard (30 – 60 calendar days)– You can request a standard appeal for a case that involves medical coverage or payment determinations. We must give you a decision no later than 30 calendar days after receiving your appeal for medical coverage or no later than 60 calendar days after receiving your appeal for claims payment.
What Do I Include with My Appeal?
You should include your name, address, and Member ID number. You should also identify the decision you are appealing, the reasons for your appeal, and include any evidence you wish to attach.
How Do I Request an Appeal?
To start an appeal, you, your doctor, or your representative must contact us.
MEDICAL – PART C
For an Expedited Appeal (72 Hours): We suggest contacting us by telephone or submitting your request by fax. Be sure to ask for a “fast or expedited review.” This means you are asking us to give you an answer using the expedited deadline rather than the standard deadline. You can call Member Services using the phone number on the back of your ID card: 667-262-9412 or 866-675-3944 or TTY/TDD 711.
For a Standard Appeal (30-60 calendar days): Make your standard appeal in writing by submitting a request. Standard appeals must be in writing. Please send your appeal to us at the address or fax number below:
Alterwood Advantage
Appeals & Grievances Department
PO Box 4175
Timonium, MD 21094-4175
Fax: 410-801-5704
PHARMACY DRUGS – PART D
For an Expedited Appeal (24 Hours): Be sure to ask for a “fast or expedited review.” This means you are asking us to give you an answer using the expedited deadline rather than the standard deadline. To request an expedited appeal, you can call us, fax your appeal, or complete the online form:
Phone: 667-261-8050 or 866-267-3144
Fax: 877-503-7231
Or go to https://elixirsolutions.promptpa.com and select “Member” to complete the Coverage Decision and Exception Request Form.
For a Standard Appeal (72 Hours): To request a standard appeal in writing, you can send your appeal to the address below, fax your appeal, or complete the online form:
Elixir
Attn: Appeals Department
2181 E. Aurora Rd., Suite 201
Twinsburg, OH 44087
Fax: 877-503-7231
Or go to https://elixirsolutions.promptpa.com and select “Member” to review and complete the Coverage Decision and Exception Request Form.
For more information about your appeal rights, you can call Member Services at the number located on the back of your ID card, refer to the Evidence of Coverage in the Member Resources page of this website, or visit the About Us – Contact Us page of this website.
Medicare Non-Participating Provider Appeal Rights
Payment Appeals Submission Requirements and Review Process:
If a non-contracted Medicare provider disagrees with a claim payment denial, they have 60 calendar days from the initial decision (organization determination) date to file a written payment appeal.
A written request for a payment appeal, along with any supporting documentation and a completed Waiver of Liability form, must be sent to the Plan’s Appeals & Grievances Mailing Address:
Alterwood Advantage
Appeals & Grievances Department
PO Box 4175
Timonium, MD 21094-4175
Upon receipt of a valid request for a payment appeal, the Plan has 60 calendar days to review and respond. Note that to be considered a valid payment appeal, the appeal request must include a completed and signed Waiver of Liability (WOL) form. If the WOL is not submitted or is incomplete, the appeal case will be sent to CMS’ Independent Review Entity for dismissal at the end of the appeal timeframe.
If Alterwood Advantage upholds the initial determination in whole or in part, the Plan must forward the appeal case to the CMS Independent Review Entity (IRE) for a second level review. The current CMS IRE for payment appeals is MAXIMUS Federal Services. The CMS IRE will review the case and send a resolution to the provider and the Plan.
Download a copy of our Waiver of Liability form
Grievances
What is a Grievance?
The Grievance process is only used for certain types of problems. This includes problems related to quality of care, waiting times, and the customer service you experience.
Here are examples of your concerns that can be handled by the Grievance process:
| Grievance Process |
|---|
| Quality of your medical care |
| • Are you unhappy with the quality of the care you have received (including care in the hospital)? |
| Respecting your privacy |
| • Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential? |
| Disrespect, poor customer service or other negative behaviors |
| • Has someone been rude or disrespectful to you? • Are you unhappy with how our Member Services has treated you? • Do you feel you are being encouraged to leave the plan? |
| Waiting times |
| • Are you having trouble getting an appointment, or waiting too long to get it? • Have you been kept waiting too long by doctors, pharmacists, or other health professionals? Or by our Member Services or other staff at the plan • Examples include waiting too long on the phone, in the waiting room, when getting a prescription, or in the exam room. |
| Cleanliness |
| • Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor’s office? |
| Information we provide you |
| • Do you believe we have not given you a notice that we are required to give? • Do you think written information we have given you is hard to understand? |
| Timeliness – the timeliness of our actions related to coverage decisions and appeals |
| If you are asking for a decision or making an appeal, you use the appeal process, not the grievance process. However, if you have already asked us for a coverage decision or requested an appeal, and you think that we are not responding quickly enough, you can also file a grievance about our slowness. Examples include: • If you have asked us to give you a “fast coverage decision” or a “fast appeal, and we have said we will not, you can file a grievance. • If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can file a grievance. • When a coverage decision we made is reviewed and we are told that we must cover or reimburse you for certain medical services or drugs, there are deadlines that apply. If you think we are not meeting these deadlines, you can file a grievance. • When we do not give you a decision on time, we are required to forward your case to the Independent Review Entity. If we do not forward it within the required deadline, you can file a grievance. |
How Do I File a Grievance?
To file a grievance, you can visit the About Us – Contact Us page of this website, refer to the Evidence of Coverage in the Member Resources page of this website, or call Member Services using the number on the back of your ID card: 667-262-9412 or 866-675-3944 or TTY/TDD 711.
Or if you put your grievance in writing, we will respond to your grievance in writing. You can email your grievance to us at MemberServices@AlterwoodHealth.com, or submit your written grievance to us at:
Alterwood Advantage
Appeals & Grievances Department
PO Box 4175
Timonium, MD 21094-4175
Grievances must be submitted within 60 calendar days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your grievance. We may extend the time frame by up to 14 calendar days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we do not accept your grievance in the whole or in part, our written decision will explain why it was not accepted and will tell you about any dispute resolution options you may have.
Whether you call or write, you should contact Member Services right away. Grievances must be made within 60 calendar days after you had the problem you want to complain about.
If you are making a grievance because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” grievance. If you have a “fast” grievance, it means we will give you an answer within 24 hours.
MEDICARE.GOV COMPLAINT WEBSITE
Below is a direct link on the grievance/coverage determination webpage to the Medicare.gov complaint website at:
https://www.medicare.gov/MedicareComplaintForm/home.aspx where an enrollee can enter a complaint in lieu of calling 1-800-MEDICARE.
Appointing Someone to Act on Your Behalf
How to appoint someone to act on your behalf
You may name a relative, friend, advocate, doctor or anyone else as your “appointed representative” to act for you. You may already have a representative authorized under State law to act for you; however, if you want someone to act for you, you and your representative must sign and date a statement giving the person legal permission to be your appointed representative. Please contact your plan for more information.
Use the form below to appoint any individual (such as a relative, friend, advocate, attorney, physician or other prescriber, or an employee of a pharmacy, charity, state pharmaceutical assistance program, or other secondary payer) to act as your representative for Coverage Decisions, Appeals, and Grievances.
Download a copy of our Appointment of Representative Form
Download a copy of the CMS Appointment of Representative Form