In this guide 4 sections
This is a Medicare HMO referral dispute involving access to cancer specialists after a hospital stay. The first step is to ask the plan to expedite the pending appeal and have a physician explain why the standard wait could put the enrollee’s health or function at serious risk.
Can the plan decide the appeal faster?
An enrollee or a physician can ask the Medicare Advantage plan for an expedited reconsideration. The request may be oral or written. A physician may provide oral or written support, even if that physician is not affiliated with the plan.
What should you ask the plan to arrange now?
- 1.Ask for the name of an available in network cancer specialist and the earliest appointment the plan can arrange.
- 2.Ask how the plan will ensure access to medically necessary specialty care if the primary care provider will not make the referral.
- 3.If the network cannot meet the medical need, ask for an organization determination authorizing an out of network specialist at in network cost sharing.
- 4.Ask the plan to put every decision in writing. Keep the appeal number, names, dates, and copies of notices.
Can you complain about the referral handling too?
Yes. A grievance is separate from an appeal. It can address plan or provider conduct, delays, or how the referral problem was handled. A grievance may be filed orally or in writing, generally within 60 days of the event.
Who can help while the decision is pending?
A local State Health Insurance Assistance Program provides free Medicare counseling. SHIP counselors can help families review coverage and file complaints or appeals. Medicare also offers help by phone at 1-800-MEDICARE and through live chat, 24 hours a day, 7 days a week except some federal holidays.
Questions families ask
Does the HMO have to approve the same cancer specialists who treated the patient in the hospital?
Not necessarily. Medicare HMOs generally require care from network providers and may require a referral. Ask the plan whether those specialists are in network and whether their services are authorized.
What if no network specialist can meet the patient’s needs?
A Medicare Advantage coordinated care plan must arrange and cover a medically necessary covered benefit outside its network, at in network cost sharing, when its network is unavailable or inadequate to meet the enrollee’s medical needs.
Can a doctor request the faster appeal?
Yes. A physician may request an expedited reconsideration and provide oral or written support, even if the physician is not affiliated with the Medicare Advantage plan.
Is a grievance the same as the appeal?
No. The appeal challenges the coverage or authorization decision. A grievance addresses other complaints about the plan, a provider, delays, or how the matter was handled.
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