Physicians Health Choice : Members : Appeals and Grievances

Physicians Health Choice (PHC) encourages you to let us know if you have questions, concerns, or problems related to your covered services or the care you receive.

This section explains the rules for filing complaints in different types of situations. Federal law guarantees your right to open a complaint if you have concerns or problems with any part of your medical care as a plan member. The Medicare program has helped set the rules about what you need to do to open a complaint and what we are required to do when we receive a complaint. If you open a complaint, we must be fair in how we handle it. You cannot be disenrolled or penalized in any way if you open a complaint.

WHAT ARE APPEALS AND GRIEVANCES?

Physicians Health Choice (PHC) encourages you to let us know if you have questions, concerns, or problems related to your covered services or the care you receive.

An Appeal is the type of complaint you make when you want PHC to reconsider and change a decision made about what services or benefits are covered for you or what PHC paid for a service or benefit. For example, if PHC refuses to cover or pay for services you think should be covered, you can file an appeal. If PHC or a plan provider refuses to provide a service you think should be covered, you can file an appeal. If Physicians Health Choice or a plan provider reduces services or benefits you have been receiving, you can file an appeal. If you think PHC is ending your coverage of a service or benefit too soon, you can file an appeal.

A Grievance is the type of complaint you make if you have any other type of problem with PHC or a plan provider. For example, you can file a grievance if you have a problem with the quality of your care, waiting times for appointments or in the exam room, the way your doctors or others behave, your ability to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor’s office.

WHAT ARE APPEALS AND GRIEVANCES?

Complaints about what PHC will cover or pay for you. If PHC or your doctor or another plan provider has refused to provide a service you think is covered, you can open a complaint called an appeal. If PHC has refused to pay for a service you think is covered, you can make an appeal. If you have been receiving a covered service, and you think that service is being reduced or ending too soon, you can make an appeal. When you file an appeal, you are asking PHC to reconsider and change a decision made about what services are covered for you (which includes whether PHC will pay for your care or how much will be paid).

Complaints about your Part D prescription drug benefits that PHC will cover or pay for. If PHC refuses to provide a Part D prescription drug benefit that you think is covered, you can request an appeal. If PHC has refused to pay for a Part D prescription drug that you have already received and you believe that it is covered, you can make an appeal. If you have been receiving a Part D prescription drug, and you think its coverage is being reduced or ending too soon, you can make an appeal. When you file an appeal, you are asking PHC to reconsider and change a decision made about what Part D prescription drug we will cover for you (which includes whether PHC will pay for a Part D prescription drug that you have already received, or how much will be pay).

An exception is a type of coverage determination that is unique to the Part D benefit. You may request a tiering exception or a formulary exception.

Tiering Exception: If granted this allows you to obtain a non-preferred drug at the cost-sharing amount applicable to drugs on the preferred tier.

Formulary Exception: If granted this ensures that you will have access to medically necessary Part D drugs that are not included on Physicians Health Choice’s formulary. Also permits you to request an exception to a quantity or dose limit or a requirement that you try another drug before Physicians Health Choice will pay for the requested drug.

Complaints if you think you are being discharged from the hospital too soon. There is a special type of appeal that applies only to hospital discharges. If you think PHC’s coverage of your hospital stay is ending too soon, you can appeal immediately to the Texas Medical Foundation (TMF) Health Quality Institute, which is the Quality Improvement Organization (QIO) in the state of Texas. TMF Health Quality Institute is a group of health professionals in Texas that is paid to handle this type of appeal from Medicare patients. If you make this type of appeal, your stay may be covered during the time period the QIO uses to make its determination. You have a very limited amount of time to appeal. Please refer to Section 11 (page 50) of the PHC Evidence of Coverage or contact PHC Member Service or the TMF Health Quality Institute at 1-800-725-9216, for instructions.

Complaints if you think your coverage for Skilled Nursing Facility (SNF), Home Health (HHA) or Comprehensive Outpatient Rehabilitation Facility (CORF) services is ending too soon. There is another special type of appeal that applies only when coverage will end for SNF, HHA or CORF services. If you think you coverage is ending too soon, you must appeal by noon of the first working day after receiving written notice of discharge directly and immediately to TMF Health Quality Institute. If you make this type of appeal, your stay may be covered during the time period the QIO uses to make its determination. A determination of this type of appeal will be made by QIO and notify you by the close of business of the first working day after it receives all necessary information from the hospital.

Complaints about any other type of problem you have with Physicians Health Choice or a plan provider. If you want to make a complaint about any type of problem other than those that are listed above, a grievance is the type of complaint you would make. For example, you would file a grievance to complain about problems with the quality or timeliness of your care, waiting times for appointments or in the exam room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor’s office. Generally, you would file the grievance with Physicians Health Choice.