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P&P Workbook 1.16

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U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U2481 Part D Appeal - Case Status Model Notice 8511.4931 Closed 18.6 U2488 Part D Appeal Notice of Redetermination 8306.2624 Closed 18.4 U2491 Part D Appeal - Request for Reconsideration Model Ltr 8591.311 Closed 18.13 U2493 CAG Notice of Plan's Decision Regarding a Grievance - Part D 8592.3812 Closed 18.8 U2493 Part D Grievance Decision/Resolution Letter 11597.5225 Canceled 18.8 U2494 Part D Grievance Extension Letter 11598.5712 Canceled 18.7 U2494 Part D Grievance Extension Letter 8512.2401 Closed 18.7 U2632 MA Expedited Appeal Not Granted letter vs New Model Notice of Right to an Expedited Grievance 11596.4626 Canceled 13.6 U2632 MA Expedited Appeal Not Granted letter vs New Model Notice of Right to an Expedited Grievance 8198.1628 Closed 13.6 U3266 Appeal Resolution Claims Overturn 10009.46 Canceled N/A U5137 CAG Acknowledgement Letter - Medicare 7873.4017 Closed No U5137 CAG Acknowledgement Letter - Medicare 8091.1327 Closed No U5137 CAG Acknowledgement Letter - Medicare 8195.0654 Closed No U5138 CAG Acknowledgement AOR letter 8267.5835 Closed No U5138 CAG Acknowledgement AOR letter - Medicare 7873.4828 Closed No
U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5138 CAG Acknowledgement AOR letter - Medicare 8589 Closed No U5138 CAG Acknowledgement AOR letter - Medicare 10915.3615 Closed No U5139 CAG Case Misclassification Letter - Medicare 7875.5446 Closed No U5139 CAG Case Misclassification Letter - Medicare 8239.2857 Closed No U5157 CAG - Medicare Resolution Letter 7884.2439 Closed 13.10 U5157 CAG - Medicare Resolution Letter 8215.1503 Closed 13.10 U5158 Medicare Dismissal - Resolution Letter 7884.2254 Closed No U5160 CAG - Medicare Withdrawal Letter 7884.3238 Closed No U5160 CAG - Withdrawal Letter 8223.0331 Closed No U5161 CAG - Medicare QOC Letter 7884.4315 Closed No U5161 CAG - QOC Letter 10287.0136 Canceled N/A U5174 CAG CTM Complaint Acknowledgement Letter - Non Model 8078.5442 Closed Yes U5177 CMS Notice of Appeal Status Model Letter 8080.1929 Closed 13.10 U5211 CAG Medicare Extension Letter 8209.5154 Closed No U5216 Part D-Notice of Plan Decision to Extend Deadline for a Grievance Decision 8225.1918 Closed 18.7
U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5218 Part D Notice of Right to Expedited Grievance 8240.5248 Closed 18.3 U5297 CAG Request for Additional Information - Part D 8594.0541 Closed 18.11 U5298 CAG - Letter to Judge and Mbr with the State Agency Appeal Summary 8605.0859 Canceled No U5299 CAG - SFH Issue Resolved before Hearing Updated 8606.2827 Canceled No U5300 CAG - State Agency Appeal Summary 8607.3726 Canceled No U5435 UCare CAG Complaint Form 9295.0427 Closed U5435 UCare CAG Complaint Form 8945.3107 Closed No U5651 Exchange - Oral Complaint Resolution Letter 9796.1549 Closed No U5652 Exchange Written Complaint Extension Letter 9797.5154 Closed No U5653 Exchange Written Complaint Non Timely Request Letter 9798.3714 Closed No U5654 Exchange Written Complaint Resolution Letter 9799.4649 Closed No U5655 Exchange Written or Oral Appeal Extension Letter 9800.4845 Closed No U5656 Exchange Written or Oral Appeal Non Timely Request Letter 9801.5124 Closed No U5657 Exchange Appeal Withdrawal Confirmation Letter 9802.5348 Closed No U5658 Exchange Appeal Resolution - Claims Overturn Letter 9803.5713 Closed No
U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5659 Exchange Appeal Resolution - Claim Partial Uphold Letter 9804.5948 Closed No U5660 Exchange Appeal Resolution - Claims Upheld no mm liability Letter 9805.0215 Closed No U5661 Exchange Appeal Resolution - Formulary Overturn Letter 9806.1858 Closed No U5662 Exchange Appeal Resolution - Formulary Partial Upheld Letter 9807.3832 Closed No U5663 Exchange Appeal Resolution - Formulary Upheld Letter 9808.4228 Closed No U5664 Exchange Appeal Resolution Restriction - Overturn Letter 9809.4456 Closed No U5665 Exchange Appeal Resolution Service - Overturn Letter 9811.4751 Closed No U5666 Exchange Appeal Resolution Service - Part Upheld Letter 9812.5017 Closed No U5667 Exchange Complaint Withdrawal Confirmation Letter 9813.5323 Closed No U5668 Exchange Member Rights How to Make an Appeal Letter 9814.5652 Canceled No U5669 Exchange Oral Appeal Claims Acknowledgement Letter 9817.3739 Closed No U5670 Exchange Oral Appeal Formulary Acknowledgement Letter 9818.4252 Closed No U5671 Exchange Oral Appeal Restriction Acknowledgement Letter 9819.4405 Closed No U5672 Exchange Oral Appeal Service Acknowledgement Letter 9820.4559 Closed No U5673 Exchange Quality of Care Complaint Letter 9821.4749 Closed No
U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5674 Exchange Written Appeal Claims Acknowledgement Letter 9822.5013 Closed No U5675 Exchange Written Appeal Formulary Acknowledgement Letter 9823.5232 Closed No U5676 Exchange Written Appeal Restriction Acknowledgement Letter 9824.5419 Closed No U5677 Exchange Written Appeal Service Acknowledgement Letter 9825.5559 Closed No U5678 Exchange Written Complaint Misclassification Acknowledgement Letter 9826.5801 Closed No U5679 Exchange Appeal Resolution Restriction - Upheld Letter 9827.1158 Closed No U5680 Exchange Appeal Resolution Service - Upheld Letter 9828.1632 Closed No U5690 Medicare Notice of Dismissal of Appeal Request Form 9911.0241 Closed Yes MA Model Notice of Dismissal of Appeal Request [ZIP, 217KB] U5690 Medicare Notice of Dismissal of Appeal Request Form 10100.1622 Closed Yes MA Model Notice of Dismissal of Appeal Request [ZIP, 217KB] U5705 SPP Appeal Resolution Claims Overturn 10010.5537 Closed U5706 SPP Appeal Resolution Claims Partial Uphold 10011.2436 Closed U5707 SPP Appeal Resolution Claims Uphold NO MBR LIABILITY 10012.3331 Closed U5708 SPP Appeal Resolution Formulary Overturn 10013.1257 Closed U5709 SPP Appeal Resolution Formulary Partial Uphold 10014.1902 Closed U5710 SPP Appeal Resolution Formulary Uphold 10015.2113 Closed
U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5711 SPP Appeal Resolution Service Overturn 10016.2407 Closed U5712 SPP Appeal Resolution Service Partial Uphold 10017.2639 Closed U5713 SPP Appeal Resolution Service Uphold 10018.3053 Closed U5714 SPP Oral Grievance Resolution 10019.3325 Closed U5715 SPP Written Grievance Resolution 10020.3948 Closed U5716 SPP Appeal Resolution Restriction Overturn 10021.4338 Closed U5717 SPP Appeal Resolution Restriction Uphold 10022.4902 Closed U5718 SPP Appeal Resolution PCA Partly Upheld 10023.523 Closed U5719 SPP Appeal Resolution PCA Partial Uphold 10024.1535 Canceled U5720 SPP Appeal Resolution PCA Uphold 10025.215 Closed U5721 SPP Appeal Withdrawal Confirmation 10026.2619 Closed U5722 SPP Grievance Withdrawal Confirmation 10027.343 Closed U5723 SPP Oral Appeal Acknowledgement Claims 10028.4411 Closed U5724 SPP Oral Appeal Acknowledgement Formulary 10029.5139 Closed U5725 SPP Oral Appeal Acknowledgement PCA 10030.5537 Closed
U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5726 SPP Oral Appeal Acknowledgement Service 10032.0026 Closed U5727 SPP Oral Appeal Acknowledgement Restriction 10031.5734 Closed U5728 SPP Written Appeal Acknowledgement Claims 10033.0343 Closed U5730 SPP Written Appeal Acknowledgement Formulary 10034.0806 Closed U5731 SPP Written Appeal Acknowledgement PCA 10035.1237 Closed U5732 SPP Written Appeal Acknowledgement Restriction 10036.1447 Closed U5733 SPP Written Appeal Acknowledgement Service 10037.17 Closed U5734 SPP Written Grievance Acknowledgement- Misclassification of Case 10038.1927 Closed U5735 SPP Written Grievance Non-Timely Request 10039.2426 Closed U5736 SPP Written Grievance Extension 10041.431 Closed U5737 SPP Oral Grievance Extension 10042.0712 Closed U5738 SPP Appeal Extension Written or Oral 10043.1309 Closed U5739 SPP Expedited Oral Appeal Request NOT Granted 10044.2728 Closed U5740 SPP Expedited Written Appeal Request NOT Granted 10045.412 Closed U5741 SPP SFH Resolved before Hearing 10046.4411 Closed
U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5742 SPP SFH PCA: NO CONTINUATION of BENEFIT 10047.5043 Closed U5743 SPP SFH PCA: YES CONTINUATION of BENEFIT 10060.2218 Closed U5744 SPP SFH Service: YES CONTINUATION of BENEFIT 10062.3624 Closed U5745 SPP SFH Service: NO CONTINUATION of BENEFIT 10061.2953 Closed U5786 DSNP Oral Appeal Acknowledgement Claims & Req for AOR 10158.1918 Closed U5787 DSNP Oral Appeal Acknowledgement Service & Req for AOR 10166.4203 Closed U5788 DSNP Written Appeal Acknowledgement Claims & Req for AOR 10168.4722 Closed U5789 DSNP Written Appeal Acknowledgement Service & Req for AOR 10169.5958 Closed U5790 DSNP Appeal Resolution Claims NO MBR LIABILITY-no auth 10170.1425 Closed U5791 DSNP Appeal Resolution Claims Overturn 10172.1623 Closed U5814 DSNP Written Grievance Acknowledgment - Misclassification of Case 10262.5749 Closed No U5815 DSNP Written Grievance Acknowledgement AND Req for AOR 10263.0239 Closed No U5816 DSNP Written Grievance Non-Timely Request 10271.25 Closed No U5817 DSNP Oral Grievance Extension 10285.2052 Closed No U5818 DSNP Written Grievance Extension 10286.2653 Closed No
U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5819 DSNP Grievance Withdrawal Confirmation 10289.3034 Closed No U5820 DSNP Oral Grievance Resolution 10290.0313 Closed No U5821 DSNP Written Grievance Resolution 10291.1632 Closed No U5822 DNSP Notice of Right to an Expedited Grievance 10292.5807 Closed No U5823 DSNP Appeal Resolution Claims Upheld 10297.0617 Closed No U5824 DSNP Appeal Resolution Service Partially Upheld 10301.4848 Closed No U5825 DSNP Appeal Resolution Service Overturn 10302.5955 Closed No U5826 DSNP Appeal Withdrawal Confirmation 10310.2155 Closed No U5828 Goadouachy 10306.4707 Closed No
Document # NCQA Compliance Name/Link Compliance Approved HUB Name/Link HUB Approved Original documents Same/Different Document Type Federal State SNP Exchange QAG-0001 Monitoring of Complaints, Appeals and Grievances Thresholds Archived QAG-0001 Monitoring of Complaints, Appeals and Grievances Thresholds Archived Procedure 0003 RR2 QAG-0003 Written Grievances 2013 March-13 QAG-0003 - Written Grievances November-13 Different Grievance Yes Yes Yes No Procedure ARCHIVING - Customer Service Now Maintains this 0004 RR2 QAG-0004 - Oral Grievances March-13 QAG-0004 - Oral Grievances March-13 Different Grievance Yes Yes Yes Yes Procedure 0005 QAG-0005 Tracking Complaints Appeals and Grievances and File Management March-13 missing Different Other Yes Yes Yes No Procedure 0006 UM8 QAG-0006 Medicare Expedited Appeals March-13 QAG-0006 - Medicare Expedited Appeals October-13 Different Appeal Yes No No No Procedure 0007 UM8 QAG-0007 Medicare Advantage Standard Reconsideration March-13 QAG-0007 - Medicare Part C Member Appeals November-13 Different Appeal Yes No No No Procedure 0008 QAG-0008 Medicare Advantage - Physician Request for Appeals (Reconsideration) March-13 QAG-0008 Medicare Advantage - Physician Request for Appeals (Reconsideration) March-13 Same Appeal Yes No No No Procedure 0009 RR2 QAG-0009 - Second Level Review of Written Grievance Decision July-13 QAG-0009 - Appeal of Written Grievance Decision November-13 Different Appeal Yes Yes Yes No Procedure 0010 QAG-0010 Submission of Medicare Advantage Reconsideration Case File to MAXIMUS March-13 QAG-0010 Submission of Medicare Advantage Reconsideration Case File to MAXIMUS March-13 Same Other Yes No Yes No Procedure 0012 QAG-0012 SPP Member Expedited Appeals June-13 QAG-0012 SPP Member Expedited Appeals June-13 Same Appeal No Yes Yes No Procedure 0013 QAG-0013 SPP Member Standard Appeal June-13 QAG-0013 SPP Member Standard Appeal June-13 Same Appeal No Yes Yes No Procedure 0014 QAG-0014 State Public Programs Member State Fair Hearing July-13 QAG-0014 State Public Programs Member State Fair Hearing July-13 Same Appeal No Yes Yes No Procedure 0015 QAG-0015 Complaints from Regulators or Other Government Officials March-13 QAG-0015 Complaints from Regulators or Other Government Officials March-13 Same Other Yes Yes Yes No Procedure 0019 QAG-0019 CAG Delegation Procedure 3 2011 March-13 QAG-0019 CAG Delegation Procedure March-13 Same Other Yes Yes Yes No Procedure 0022 RR2 QAG-0022 Management of Potential Deficiencies in Clinical Quality of Care March-13 QAG-0022 Management of Potential Deficiencies in Clinical Quality of Care March-13 Same Grievance Yes Yes Yes Yes Procedure 0023 QAG-0023 Medicare Part D CAG Internal Data Collection and Reporting Process Updated 9 2012 March-13 QAG-0023 Medicare Part D CAG Internal Data Collection and Reporting Process March-13 Same Other Yes No Yes No Product Lines Affected
Document # NCQA Compliance Name/Link Compliance Approved HUB Name/Link HUB Approved Original documents Same/Different Document Type Federal State SNP Exchange Product Lines Affected Procedure 0024 QAG-0024 Medicare Part C Reporting of Grievances 3 2011 March-13 QAG-0024 Medicare Part C Reporting of Grievances March-13 Same Other Yes No Yes No Procedure 0025 QAG-0025 Medicare Part C Reporting of Reconsiderations 3 2011 CR March-13 QAG-0025 Medicare Part C Reporting of Reconsiderations CR March-13 Same Other Yes No Yes No Procedure 0026 QAG-0026 Medicare Part D Reporting of Grievances 3 2011 CR March-13 QAG-0026 - Medicare Part D Reporting of Grievances CR March-13 Same Other Yes No Yes No Procedure 0027 QAG-0027 Medicare Part C CAG Internal Data Collection and Reporting Process Updated 9 2012 March-13 QAG-0027 Medicare Part C CAG Internal Data Collection and Reporting Process September-12 Same Other Yes No Yes No Procedure 0028 QAG-0028 Medicare Part D Reporting of Appeals (Redeterminations) March-13 QAG-0028 Medicare Part D Reporting of Appeals (Redeterminations) March-13 Same Other Yes No Yes No Procedure 0029 QAG-0029 CTM Procedure March-13 QAG-0029 CTM Procedure March-13 Same Grievance Yes No Yes No Procedure 1301 QAG-1301 External Specialty Review March-13 QAG-1301 External Specialty Review March-13 Same Appeal Yes Yes Yes Yes Procedure 1601 UM8 Exchange QAG-1601 Exchange Member Appeals Missing QAG-1601 - Exchange Member Appeals September-13 Procedure 1701 RR2 Exchange QAG-1701 Exchange Member Grievances Missing QAG-1701 - Exchange Member Grievances January-14 Procedure 2201 UM8 QAG-2201 - Medicare Part D Member Appeals December-13 QAG-2201 - Medicare Part D Member Appeals December-13 Same Appeal Yes No Yes No Policy 005 QAG005 - Potential Deficiency in Clinical Quality of Care March-13 QAG005 - Potential Deficiency in Clinical Quality of Care March-13 Same Grievance Yes Yes Yes Add Policy 008 QAG008 - State Public Programs Member Complaints Appeals and Grievances July-13 QAG008 - State Public Programs Member Complaints Appeals and Grievances Jul-13 Same Grievance No Yes Yes No Policy 013 QAG013 - External Specialty Review March-13 QAG013 - External Specialty Review Jul-13 Signature date is different Appeal Yes Yes Yes Add Policy 014 UM8 QAG014 - Medicare Part C Member Appeals November-13 QAG014 - Medicare Part C Member Appeals Nov-13 Same Appeal Yes No Yes No Policy 015 QAG015 - CAG Department and Provider Reporting March-13 QAG015 - Provider Reporting of Member Grievances and Grievance Reports to UCare Departments Mar-13 Same Other Yes Yes Yes Add Policy 016 UM8 Exchange QAG016 - Exchange Member Appeals January-14 QAG016 Exchange Member Appeals Jan-14 Same Appeal No No No Yes Policy 017 RR2 Exchange QAG017 Exchange Member Grievances January-14 QAG017 Exchange Member Grievances Jan-14 Same Grievance No No No Yes
Document # NCQA Compliance Name/Link Compliance Approved HUB Name/Link HUB Approved Original documents Same/Different Document Type Federal State SNP Exchange Product Lines Affected Policy 018 RR2 QAG018 Medicare Part C Member Grievances October-13 QAG018 - Medicare Part C Member Grievances Oct-13 Same Grievance Yes No Yes No Policy 020 QAG020 - Member Grievances and Appeals UCare Senior Select December-12 QAG020 - Member Grievances and Appeals - UCare Senior Select Dec-12 Signature date is different Grievance and Appeal No No No No Policy 021 UM8 QAG021 Medicare Part D Member Appeals October-13 QAG021- Medicare Part D Member Appeals Oct-13 Same Appeal Yes No Yes No Policy 022 RR2 QAG022 Medicare Part D Member Grievances November-13 QAG022 - Medicare Part D Member Grievances Nov-13 Same Appeal Yes No Yes No Policy 023 RR2 QAG023 Second Level Review of a Written Grievance November-13 QAG023 - Second Level Review of a Written Grievance Nov-13 Same Grievance Yes Yes Yes Yes Policy 029 QAG029 - Medicare Complaint Tracking Module (CTM) March-13 QAG029 - Medicare Complaint Tracking Module Mar-13 Same Other Yes No Yes No
Word Administrative Law Judge (ALJ) Hearing Appeal Assignee Complaint Coverage Determination Delegated Entity Effectuation Expedited Appeal Expedited Organization Determination Grievance
Independent Review Entity (IRE) Inquiry Judicial Review Language Block Language Line Medicare Appeals Council (MAC) Organization Determination Other Prescriber Quality Improvement Organization (QIO)
Quality of Care Reconsideration Redetermination Representative Standard Appeal
DefinitionThe third level of the Part D appeal process, which involves a judge authorized to review and hold a hearing regarding a request from a member who disputes an adverse decision made by the Independent Review Entity (IRE). Any of the procedures that deal with the review of adverse organization determinations regarding the health care services a member believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that the delay would adversely affect the health of the member), or any amounts the member must pay for a service as defined in 42 CFR §422.566(b). These procedures include reconsiderations by UCare and, if necessary, an independent review entity; hearings before ALJs, reviews by the A non-contracted physician or other non-contracted provider who furnished a service to the member and formally agrees to waive any right to payment from the member for that service. A complaint could be either a grievance or an appeal, or a complaint could include both. Coverage Determination: A coverage determination is any determination (i.e., an approval or denial) made by UCare or its delegated entity, with respect to the following: 1. A decision about whether to provide or pay for a Part D drug (including a decision not to pay because the drug is not on the plan's formulary, because the drug is determined not to be medically necessary, because the drug is furnished by an out-of-network pharmacy, or because UCare determines that the drug is otherwise excluded under §1862(a) of the Social Security Act if applied to Medicare Part D) that the member believes may be covered by the plan. 2. Failure to provide a coverage determination in a timely manner, when a delay would adversely affect the health of the member. 3. A decision concerning a tiering exceptions request under 42 CFR §423.578(a). 4. A decision concerning a formulary exceptions request under 42 CFR §423.578(b). 5. A decision on the amount of cost sharing for a drug. Any organization or company to which UCare has contractually given the authority to carry out a particular function on behalf of UCare. An organization that assumes responsibility for providing a certain type of covered healthcare services through its own provider network on UCare's behalf. Examples include organizations that provide vision services, chiropractic services, or pharmacy benefit management services. Compliance with a reversal of UCare’s original adverse organization determination. Effectuation may entail payment of a claim, authorization for a service, or provision of services. Expedited appeals are available when precertification of urgent or ongoing services has been denied and a delay in decision making might seriously jeopardize the life or health of the member or otherwise jeopardize the An organization determination that UCare or the provider makes and communicates as soon as possible but no later than 72 hours after the request because the member’s life, health, or ability to attain, regain, or maintain maximum function could be jeopardized by waiting 14 calendar days for a decision Verbal Grievance: A grievance communicated by telephone or face-to-face. Written Grievance: A grievance communicated in writing or by e-mail. Any complaint or dispute, other than one involving an organization determination, expressing dissatisfaction with the manner in which UCare or delegated entity provides health care services regardless of whether any remedial action can be taken. Examples: • Quality of service provided, including long wait times for appointments, interpersonal aspects of care, such as rudeness by a provider or staff member (other than refusal to furnish a requested service). • Issues relating to premiums and involuntary disenrollment. • Requests for expedited determinations and appeals that have been refused and transferred to the standard process. • Disputes of UCare’s decision to invoke an extension relating to an organization determination or reconsideration.
An independent entity contracted by CMS to review Medicare health plans’ adverse reconsiderations of organization determinations. MAXIMUS Federal Services is the current IRE. Any oral or written request to UCare, a provider, or a facility without expression of dissatisfaction, e.g., a request for information or action by a member. The fifth level of the appeal process, which involves a Federal District Court review of an ALJ decision if the ALJ hearing and/or MAC review is unfavorable to the member, in whole or in part, and the amount remaining in The language block is a graphic block of text that informs readers, in multiple languages,* how they can get help with understanding the information in a particular document at no cost to them. The Language Line is a service that connects human interpreters via telephone to individuals who wish to speak to each other but do not share a common language. The telephone interpreter converts the spoken language from one language to another, enabling listeners and speakers to understand each other. The fourth level of the appeal process, which involves a board authorized to review a request from any party including a member or UCare in which there is a dispute of the ALJ’s adverse decision or dismissal of the Any decision made by or on behalf of UCare regarding payment or services to which a member believes he or she is entitled. An organization determination as defined by 42 CFR §422.566(b) is any determination made with respect to any of the following: • Payment for temporary out-of-area renal dialysis services, emergency services, post-stabilization care, or urgently needed services. • Payment for any other health services furnished by a provider other than UCare that the member believes are covered under Medicare, or if not covered under Medicare should have been furnished, arranged for, or reimbursed by UCare. • UCare’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the member believes should be furnished or arranged for by UCare. • Discontinuation of a service if the member believes that continuation of the service is medically necessary. • Failure of UCare to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the member with timely notice of an adverse determination, such that a delay would adversely affect the health of the member. A health care professional other than a physician who is authorized under State law or other applicable law to An organization comprised of practicing doctors and other health care experts under contract to the federal government to monitor and improve the care given to Medicare members. A QIO reviews complaints raised by members about the quality of care provided by physicians, inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities (SNFs), home health agencies, Medicare health plans, and ambulatory surgical centers. The QIOs also review continued stay denials in acute inpatient hospital facilities as
Concerns involving situations where the reporter indicated that the quality of clinical care or quality of service adversely affected, or has the potential to adversely affect, a member’s health or well-being. See Policy QAG005 for full definition of Quality of Care. The following are examples of potential QOC issues that could be reported to UCare Quality Management (QM) for additional investigation: • Provider skill or knowledge (procedural error, post-procedural complication, clinical knowledge, treating or diagnosing outside the scope of practice, provider behavior or communication, etc.). • Evaluation/Assessment (incomplete exam or a problem with the quality of the exam, diagnostic work-up not complete, delay in referring or scheduling surgery or procedure/test, delay in diagnosis, incorrect diagnosis, etc.). • Treatment (inappropriate or incorrect treatment, delay in treatment, failure to treat, ineffective or incomplete treatment, etc.). • Coordination/Continuity of care (delay or failure in provider follow-up, failure to seek consultation or second opinion, premature discharge from hospital or facility, lack of communication in response to problems identified by other providers, access to care, multiple providers and lack of communication or coordination, etc.). • General care (perceived poor care, inadequate staff skills to provide care needed, care not provided as ordered or prescribed, safety or environmental issues in care facility, incomplete or incorrect nursing or ancillary assessment, etc.). • Medical equipment (equipment malfunction leading to member harm, equipment not available for care, equipment not appropriate for member needs, improper use of equipment leading to patient harm, etc.). The second level of the appeal process, which involves the IRE's review of an adverse redetermination decision, the evidence and findings upon which it was based, and any other evidence the member submits or the IRE The first level of the appeal process, which requires UCare to review an adverse coverage determination decision, the findings upon which it was based, and any other evidence submitted or obtained. An individual appointed by a member or other party, or authorized under state or other applicable law, to act on behalf of a member or other party involved in an appeal or grievance. Unless otherwise stated, the representative has all of the rights and responsibilities of a member or party in obtaining an organization determination, filing a grievance, or in dealing with any of the levels of the appeals process, subject to the A written request from a member or representative asking UCare to reconsider an adverse organization determination made by UCare or a delegated entity.
QAG-0003 QAG-0005 QAG-0006 QAG-0007 QAG-0008 3 5 6 7 8 3 5 6 3 5 6 5 6 5 6 7 8 7 3 5 6
5 6 5 5 5 3 6 7 5 6
3 5 5 6 7 8 5 3 5 6 7 5 6 7 8
QAG-0009 QAG-0010 QAG-0012 QAG-0013 QAG-0014
QAG-0015 QAG-0019 QAG-0022 QAG-0023 QAG-0024
QAG-0025 QAG-0026 QAG-0027 QAG-0028 QAG-0029
QAG-1301 QAG-1601 QAG-1701
Aging Report Run daily; Monday an enhanced copy is sent Coordinators will reply with a case status, which will be added to column A. There are macros built into the document that help step you through the process. Click Here for Aging Report Timeliness Report Run around the 15th of the month. Jill will send the source document in a spreadsheet for you. Click on "Blank Timeliness Report." You will also want to upload a copy of the source document that Jill sends you in this shared point site Click here for Timeliness Report CTM Report Also run around the 15 of the month. Information is extracted from CTM for this report. Click on "copy of ctm report" file. You will need to click on the open tab and re-select open and click the closed tab and re-select close, then fill in all yellow sections of the report Click here tor CTM Report

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P&P Workbook 1.16

  • 1. U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U2481 Part D Appeal - Case Status Model Notice 8511.4931 Closed 18.6 U2488 Part D Appeal Notice of Redetermination 8306.2624 Closed 18.4 U2491 Part D Appeal - Request for Reconsideration Model Ltr 8591.311 Closed 18.13 U2493 CAG Notice of Plan's Decision Regarding a Grievance - Part D 8592.3812 Closed 18.8 U2493 Part D Grievance Decision/Resolution Letter 11597.5225 Canceled 18.8 U2494 Part D Grievance Extension Letter 11598.5712 Canceled 18.7 U2494 Part D Grievance Extension Letter 8512.2401 Closed 18.7 U2632 MA Expedited Appeal Not Granted letter vs New Model Notice of Right to an Expedited Grievance 11596.4626 Canceled 13.6 U2632 MA Expedited Appeal Not Granted letter vs New Model Notice of Right to an Expedited Grievance 8198.1628 Closed 13.6 U3266 Appeal Resolution Claims Overturn 10009.46 Canceled N/A U5137 CAG Acknowledgement Letter - Medicare 7873.4017 Closed No U5137 CAG Acknowledgement Letter - Medicare 8091.1327 Closed No U5137 CAG Acknowledgement Letter - Medicare 8195.0654 Closed No U5138 CAG Acknowledgement AOR letter 8267.5835 Closed No U5138 CAG Acknowledgement AOR letter - Medicare 7873.4828 Closed No
  • 2. U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5138 CAG Acknowledgement AOR letter - Medicare 8589 Closed No U5138 CAG Acknowledgement AOR letter - Medicare 10915.3615 Closed No U5139 CAG Case Misclassification Letter - Medicare 7875.5446 Closed No U5139 CAG Case Misclassification Letter - Medicare 8239.2857 Closed No U5157 CAG - Medicare Resolution Letter 7884.2439 Closed 13.10 U5157 CAG - Medicare Resolution Letter 8215.1503 Closed 13.10 U5158 Medicare Dismissal - Resolution Letter 7884.2254 Closed No U5160 CAG - Medicare Withdrawal Letter 7884.3238 Closed No U5160 CAG - Withdrawal Letter 8223.0331 Closed No U5161 CAG - Medicare QOC Letter 7884.4315 Closed No U5161 CAG - QOC Letter 10287.0136 Canceled N/A U5174 CAG CTM Complaint Acknowledgement Letter - Non Model 8078.5442 Closed Yes U5177 CMS Notice of Appeal Status Model Letter 8080.1929 Closed 13.10 U5211 CAG Medicare Extension Letter 8209.5154 Closed No U5216 Part D-Notice of Plan Decision to Extend Deadline for a Grievance Decision 8225.1918 Closed 18.7
  • 3. U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5218 Part D Notice of Right to Expedited Grievance 8240.5248 Closed 18.3 U5297 CAG Request for Additional Information - Part D 8594.0541 Closed 18.11 U5298 CAG - Letter to Judge and Mbr with the State Agency Appeal Summary 8605.0859 Canceled No U5299 CAG - SFH Issue Resolved before Hearing Updated 8606.2827 Canceled No U5300 CAG - State Agency Appeal Summary 8607.3726 Canceled No U5435 UCare CAG Complaint Form 9295.0427 Closed U5435 UCare CAG Complaint Form 8945.3107 Closed No U5651 Exchange - Oral Complaint Resolution Letter 9796.1549 Closed No U5652 Exchange Written Complaint Extension Letter 9797.5154 Closed No U5653 Exchange Written Complaint Non Timely Request Letter 9798.3714 Closed No U5654 Exchange Written Complaint Resolution Letter 9799.4649 Closed No U5655 Exchange Written or Oral Appeal Extension Letter 9800.4845 Closed No U5656 Exchange Written or Oral Appeal Non Timely Request Letter 9801.5124 Closed No U5657 Exchange Appeal Withdrawal Confirmation Letter 9802.5348 Closed No U5658 Exchange Appeal Resolution - Claims Overturn Letter 9803.5713 Closed No
  • 4. U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5659 Exchange Appeal Resolution - Claim Partial Uphold Letter 9804.5948 Closed No U5660 Exchange Appeal Resolution - Claims Upheld no mm liability Letter 9805.0215 Closed No U5661 Exchange Appeal Resolution - Formulary Overturn Letter 9806.1858 Closed No U5662 Exchange Appeal Resolution - Formulary Partial Upheld Letter 9807.3832 Closed No U5663 Exchange Appeal Resolution - Formulary Upheld Letter 9808.4228 Closed No U5664 Exchange Appeal Resolution Restriction - Overturn Letter 9809.4456 Closed No U5665 Exchange Appeal Resolution Service - Overturn Letter 9811.4751 Closed No U5666 Exchange Appeal Resolution Service - Part Upheld Letter 9812.5017 Closed No U5667 Exchange Complaint Withdrawal Confirmation Letter 9813.5323 Closed No U5668 Exchange Member Rights How to Make an Appeal Letter 9814.5652 Canceled No U5669 Exchange Oral Appeal Claims Acknowledgement Letter 9817.3739 Closed No U5670 Exchange Oral Appeal Formulary Acknowledgement Letter 9818.4252 Closed No U5671 Exchange Oral Appeal Restriction Acknowledgement Letter 9819.4405 Closed No U5672 Exchange Oral Appeal Service Acknowledgement Letter 9820.4559 Closed No U5673 Exchange Quality of Care Complaint Letter 9821.4749 Closed No
  • 5. U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5674 Exchange Written Appeal Claims Acknowledgement Letter 9822.5013 Closed No U5675 Exchange Written Appeal Formulary Acknowledgement Letter 9823.5232 Closed No U5676 Exchange Written Appeal Restriction Acknowledgement Letter 9824.5419 Closed No U5677 Exchange Written Appeal Service Acknowledgement Letter 9825.5559 Closed No U5678 Exchange Written Complaint Misclassification Acknowledgement Letter 9826.5801 Closed No U5679 Exchange Appeal Resolution Restriction - Upheld Letter 9827.1158 Closed No U5680 Exchange Appeal Resolution Service - Upheld Letter 9828.1632 Closed No U5690 Medicare Notice of Dismissal of Appeal Request Form 9911.0241 Closed Yes MA Model Notice of Dismissal of Appeal Request [ZIP, 217KB] U5690 Medicare Notice of Dismissal of Appeal Request Form 10100.1622 Closed Yes MA Model Notice of Dismissal of Appeal Request [ZIP, 217KB] U5705 SPP Appeal Resolution Claims Overturn 10010.5537 Closed U5706 SPP Appeal Resolution Claims Partial Uphold 10011.2436 Closed U5707 SPP Appeal Resolution Claims Uphold NO MBR LIABILITY 10012.3331 Closed U5708 SPP Appeal Resolution Formulary Overturn 10013.1257 Closed U5709 SPP Appeal Resolution Formulary Partial Uphold 10014.1902 Closed U5710 SPP Appeal Resolution Formulary Uphold 10015.2113 Closed
  • 6. U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5711 SPP Appeal Resolution Service Overturn 10016.2407 Closed U5712 SPP Appeal Resolution Service Partial Uphold 10017.2639 Closed U5713 SPP Appeal Resolution Service Uphold 10018.3053 Closed U5714 SPP Oral Grievance Resolution 10019.3325 Closed U5715 SPP Written Grievance Resolution 10020.3948 Closed U5716 SPP Appeal Resolution Restriction Overturn 10021.4338 Closed U5717 SPP Appeal Resolution Restriction Uphold 10022.4902 Closed U5718 SPP Appeal Resolution PCA Partly Upheld 10023.523 Closed U5719 SPP Appeal Resolution PCA Partial Uphold 10024.1535 Canceled U5720 SPP Appeal Resolution PCA Uphold 10025.215 Closed U5721 SPP Appeal Withdrawal Confirmation 10026.2619 Closed U5722 SPP Grievance Withdrawal Confirmation 10027.343 Closed U5723 SPP Oral Appeal Acknowledgement Claims 10028.4411 Closed U5724 SPP Oral Appeal Acknowledgement Formulary 10029.5139 Closed U5725 SPP Oral Appeal Acknowledgement PCA 10030.5537 Closed
  • 7. U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5726 SPP Oral Appeal Acknowledgement Service 10032.0026 Closed U5727 SPP Oral Appeal Acknowledgement Restriction 10031.5734 Closed U5728 SPP Written Appeal Acknowledgement Claims 10033.0343 Closed U5730 SPP Written Appeal Acknowledgement Formulary 10034.0806 Closed U5731 SPP Written Appeal Acknowledgement PCA 10035.1237 Closed U5732 SPP Written Appeal Acknowledgement Restriction 10036.1447 Closed U5733 SPP Written Appeal Acknowledgement Service 10037.17 Closed U5734 SPP Written Grievance Acknowledgement- Misclassification of Case 10038.1927 Closed U5735 SPP Written Grievance Non-Timely Request 10039.2426 Closed U5736 SPP Written Grievance Extension 10041.431 Closed U5737 SPP Oral Grievance Extension 10042.0712 Closed U5738 SPP Appeal Extension Written or Oral 10043.1309 Closed U5739 SPP Expedited Oral Appeal Request NOT Granted 10044.2728 Closed U5740 SPP Expedited Written Appeal Request NOT Granted 10045.412 Closed U5741 SPP SFH Resolved before Hearing 10046.4411 Closed
  • 8. U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5742 SPP SFH PCA: NO CONTINUATION of BENEFIT 10047.5043 Closed U5743 SPP SFH PCA: YES CONTINUATION of BENEFIT 10060.2218 Closed U5744 SPP SFH Service: YES CONTINUATION of BENEFIT 10062.3624 Closed U5745 SPP SFH Service: NO CONTINUATION of BENEFIT 10061.2953 Closed U5786 DSNP Oral Appeal Acknowledgement Claims & Req for AOR 10158.1918 Closed U5787 DSNP Oral Appeal Acknowledgement Service & Req for AOR 10166.4203 Closed U5788 DSNP Written Appeal Acknowledgement Claims & Req for AOR 10168.4722 Closed U5789 DSNP Written Appeal Acknowledgement Service & Req for AOR 10169.5958 Closed U5790 DSNP Appeal Resolution Claims NO MBR LIABILITY-no auth 10170.1425 Closed U5791 DSNP Appeal Resolution Claims Overturn 10172.1623 Closed U5814 DSNP Written Grievance Acknowledgment - Misclassification of Case 10262.5749 Closed No U5815 DSNP Written Grievance Acknowledgement AND Req for AOR 10263.0239 Closed No U5816 DSNP Written Grievance Non-Timely Request 10271.25 Closed No U5817 DSNP Oral Grievance Extension 10285.2052 Closed No U5818 DSNP Written Grievance Extension 10286.2653 Closed No
  • 9. U2481 Part D Appeal - Case Status Model Notice 11595.2338 Canceled 18.6 U5819 DSNP Grievance Withdrawal Confirmation 10289.3034 Closed No U5820 DSNP Oral Grievance Resolution 10290.0313 Closed No U5821 DSNP Written Grievance Resolution 10291.1632 Closed No U5822 DNSP Notice of Right to an Expedited Grievance 10292.5807 Closed No U5823 DSNP Appeal Resolution Claims Upheld 10297.0617 Closed No U5824 DSNP Appeal Resolution Service Partially Upheld 10301.4848 Closed No U5825 DSNP Appeal Resolution Service Overturn 10302.5955 Closed No U5826 DSNP Appeal Withdrawal Confirmation 10310.2155 Closed No U5828 Goadouachy 10306.4707 Closed No
  • 10. Document # NCQA Compliance Name/Link Compliance Approved HUB Name/Link HUB Approved Original documents Same/Different Document Type Federal State SNP Exchange QAG-0001 Monitoring of Complaints, Appeals and Grievances Thresholds Archived QAG-0001 Monitoring of Complaints, Appeals and Grievances Thresholds Archived Procedure 0003 RR2 QAG-0003 Written Grievances 2013 March-13 QAG-0003 - Written Grievances November-13 Different Grievance Yes Yes Yes No Procedure ARCHIVING - Customer Service Now Maintains this 0004 RR2 QAG-0004 - Oral Grievances March-13 QAG-0004 - Oral Grievances March-13 Different Grievance Yes Yes Yes Yes Procedure 0005 QAG-0005 Tracking Complaints Appeals and Grievances and File Management March-13 missing Different Other Yes Yes Yes No Procedure 0006 UM8 QAG-0006 Medicare Expedited Appeals March-13 QAG-0006 - Medicare Expedited Appeals October-13 Different Appeal Yes No No No Procedure 0007 UM8 QAG-0007 Medicare Advantage Standard Reconsideration March-13 QAG-0007 - Medicare Part C Member Appeals November-13 Different Appeal Yes No No No Procedure 0008 QAG-0008 Medicare Advantage - Physician Request for Appeals (Reconsideration) March-13 QAG-0008 Medicare Advantage - Physician Request for Appeals (Reconsideration) March-13 Same Appeal Yes No No No Procedure 0009 RR2 QAG-0009 - Second Level Review of Written Grievance Decision July-13 QAG-0009 - Appeal of Written Grievance Decision November-13 Different Appeal Yes Yes Yes No Procedure 0010 QAG-0010 Submission of Medicare Advantage Reconsideration Case File to MAXIMUS March-13 QAG-0010 Submission of Medicare Advantage Reconsideration Case File to MAXIMUS March-13 Same Other Yes No Yes No Procedure 0012 QAG-0012 SPP Member Expedited Appeals June-13 QAG-0012 SPP Member Expedited Appeals June-13 Same Appeal No Yes Yes No Procedure 0013 QAG-0013 SPP Member Standard Appeal June-13 QAG-0013 SPP Member Standard Appeal June-13 Same Appeal No Yes Yes No Procedure 0014 QAG-0014 State Public Programs Member State Fair Hearing July-13 QAG-0014 State Public Programs Member State Fair Hearing July-13 Same Appeal No Yes Yes No Procedure 0015 QAG-0015 Complaints from Regulators or Other Government Officials March-13 QAG-0015 Complaints from Regulators or Other Government Officials March-13 Same Other Yes Yes Yes No Procedure 0019 QAG-0019 CAG Delegation Procedure 3 2011 March-13 QAG-0019 CAG Delegation Procedure March-13 Same Other Yes Yes Yes No Procedure 0022 RR2 QAG-0022 Management of Potential Deficiencies in Clinical Quality of Care March-13 QAG-0022 Management of Potential Deficiencies in Clinical Quality of Care March-13 Same Grievance Yes Yes Yes Yes Procedure 0023 QAG-0023 Medicare Part D CAG Internal Data Collection and Reporting Process Updated 9 2012 March-13 QAG-0023 Medicare Part D CAG Internal Data Collection and Reporting Process March-13 Same Other Yes No Yes No Product Lines Affected
  • 11. Document # NCQA Compliance Name/Link Compliance Approved HUB Name/Link HUB Approved Original documents Same/Different Document Type Federal State SNP Exchange Product Lines Affected Procedure 0024 QAG-0024 Medicare Part C Reporting of Grievances 3 2011 March-13 QAG-0024 Medicare Part C Reporting of Grievances March-13 Same Other Yes No Yes No Procedure 0025 QAG-0025 Medicare Part C Reporting of Reconsiderations 3 2011 CR March-13 QAG-0025 Medicare Part C Reporting of Reconsiderations CR March-13 Same Other Yes No Yes No Procedure 0026 QAG-0026 Medicare Part D Reporting of Grievances 3 2011 CR March-13 QAG-0026 - Medicare Part D Reporting of Grievances CR March-13 Same Other Yes No Yes No Procedure 0027 QAG-0027 Medicare Part C CAG Internal Data Collection and Reporting Process Updated 9 2012 March-13 QAG-0027 Medicare Part C CAG Internal Data Collection and Reporting Process September-12 Same Other Yes No Yes No Procedure 0028 QAG-0028 Medicare Part D Reporting of Appeals (Redeterminations) March-13 QAG-0028 Medicare Part D Reporting of Appeals (Redeterminations) March-13 Same Other Yes No Yes No Procedure 0029 QAG-0029 CTM Procedure March-13 QAG-0029 CTM Procedure March-13 Same Grievance Yes No Yes No Procedure 1301 QAG-1301 External Specialty Review March-13 QAG-1301 External Specialty Review March-13 Same Appeal Yes Yes Yes Yes Procedure 1601 UM8 Exchange QAG-1601 Exchange Member Appeals Missing QAG-1601 - Exchange Member Appeals September-13 Procedure 1701 RR2 Exchange QAG-1701 Exchange Member Grievances Missing QAG-1701 - Exchange Member Grievances January-14 Procedure 2201 UM8 QAG-2201 - Medicare Part D Member Appeals December-13 QAG-2201 - Medicare Part D Member Appeals December-13 Same Appeal Yes No Yes No Policy 005 QAG005 - Potential Deficiency in Clinical Quality of Care March-13 QAG005 - Potential Deficiency in Clinical Quality of Care March-13 Same Grievance Yes Yes Yes Add Policy 008 QAG008 - State Public Programs Member Complaints Appeals and Grievances July-13 QAG008 - State Public Programs Member Complaints Appeals and Grievances Jul-13 Same Grievance No Yes Yes No Policy 013 QAG013 - External Specialty Review March-13 QAG013 - External Specialty Review Jul-13 Signature date is different Appeal Yes Yes Yes Add Policy 014 UM8 QAG014 - Medicare Part C Member Appeals November-13 QAG014 - Medicare Part C Member Appeals Nov-13 Same Appeal Yes No Yes No Policy 015 QAG015 - CAG Department and Provider Reporting March-13 QAG015 - Provider Reporting of Member Grievances and Grievance Reports to UCare Departments Mar-13 Same Other Yes Yes Yes Add Policy 016 UM8 Exchange QAG016 - Exchange Member Appeals January-14 QAG016 Exchange Member Appeals Jan-14 Same Appeal No No No Yes Policy 017 RR2 Exchange QAG017 Exchange Member Grievances January-14 QAG017 Exchange Member Grievances Jan-14 Same Grievance No No No Yes
  • 12. Document # NCQA Compliance Name/Link Compliance Approved HUB Name/Link HUB Approved Original documents Same/Different Document Type Federal State SNP Exchange Product Lines Affected Policy 018 RR2 QAG018 Medicare Part C Member Grievances October-13 QAG018 - Medicare Part C Member Grievances Oct-13 Same Grievance Yes No Yes No Policy 020 QAG020 - Member Grievances and Appeals UCare Senior Select December-12 QAG020 - Member Grievances and Appeals - UCare Senior Select Dec-12 Signature date is different Grievance and Appeal No No No No Policy 021 UM8 QAG021 Medicare Part D Member Appeals October-13 QAG021- Medicare Part D Member Appeals Oct-13 Same Appeal Yes No Yes No Policy 022 RR2 QAG022 Medicare Part D Member Grievances November-13 QAG022 - Medicare Part D Member Grievances Nov-13 Same Appeal Yes No Yes No Policy 023 RR2 QAG023 Second Level Review of a Written Grievance November-13 QAG023 - Second Level Review of a Written Grievance Nov-13 Same Grievance Yes Yes Yes Yes Policy 029 QAG029 - Medicare Complaint Tracking Module (CTM) March-13 QAG029 - Medicare Complaint Tracking Module Mar-13 Same Other Yes No Yes No
  • 13. Word Administrative Law Judge (ALJ) Hearing Appeal Assignee Complaint Coverage Determination Delegated Entity Effectuation Expedited Appeal Expedited Organization Determination Grievance
  • 14. Independent Review Entity (IRE) Inquiry Judicial Review Language Block Language Line Medicare Appeals Council (MAC) Organization Determination Other Prescriber Quality Improvement Organization (QIO)
  • 16. DefinitionThe third level of the Part D appeal process, which involves a judge authorized to review and hold a hearing regarding a request from a member who disputes an adverse decision made by the Independent Review Entity (IRE). Any of the procedures that deal with the review of adverse organization determinations regarding the health care services a member believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that the delay would adversely affect the health of the member), or any amounts the member must pay for a service as defined in 42 CFR §422.566(b). These procedures include reconsiderations by UCare and, if necessary, an independent review entity; hearings before ALJs, reviews by the A non-contracted physician or other non-contracted provider who furnished a service to the member and formally agrees to waive any right to payment from the member for that service. A complaint could be either a grievance or an appeal, or a complaint could include both. Coverage Determination: A coverage determination is any determination (i.e., an approval or denial) made by UCare or its delegated entity, with respect to the following: 1. A decision about whether to provide or pay for a Part D drug (including a decision not to pay because the drug is not on the plan's formulary, because the drug is determined not to be medically necessary, because the drug is furnished by an out-of-network pharmacy, or because UCare determines that the drug is otherwise excluded under §1862(a) of the Social Security Act if applied to Medicare Part D) that the member believes may be covered by the plan. 2. Failure to provide a coverage determination in a timely manner, when a delay would adversely affect the health of the member. 3. A decision concerning a tiering exceptions request under 42 CFR §423.578(a). 4. A decision concerning a formulary exceptions request under 42 CFR §423.578(b). 5. A decision on the amount of cost sharing for a drug. Any organization or company to which UCare has contractually given the authority to carry out a particular function on behalf of UCare. An organization that assumes responsibility for providing a certain type of covered healthcare services through its own provider network on UCare's behalf. Examples include organizations that provide vision services, chiropractic services, or pharmacy benefit management services. Compliance with a reversal of UCare’s original adverse organization determination. Effectuation may entail payment of a claim, authorization for a service, or provision of services. Expedited appeals are available when precertification of urgent or ongoing services has been denied and a delay in decision making might seriously jeopardize the life or health of the member or otherwise jeopardize the An organization determination that UCare or the provider makes and communicates as soon as possible but no later than 72 hours after the request because the member’s life, health, or ability to attain, regain, or maintain maximum function could be jeopardized by waiting 14 calendar days for a decision Verbal Grievance: A grievance communicated by telephone or face-to-face. Written Grievance: A grievance communicated in writing or by e-mail. Any complaint or dispute, other than one involving an organization determination, expressing dissatisfaction with the manner in which UCare or delegated entity provides health care services regardless of whether any remedial action can be taken. Examples: • Quality of service provided, including long wait times for appointments, interpersonal aspects of care, such as rudeness by a provider or staff member (other than refusal to furnish a requested service). • Issues relating to premiums and involuntary disenrollment. • Requests for expedited determinations and appeals that have been refused and transferred to the standard process. • Disputes of UCare’s decision to invoke an extension relating to an organization determination or reconsideration.
  • 17. An independent entity contracted by CMS to review Medicare health plans’ adverse reconsiderations of organization determinations. MAXIMUS Federal Services is the current IRE. Any oral or written request to UCare, a provider, or a facility without expression of dissatisfaction, e.g., a request for information or action by a member. The fifth level of the appeal process, which involves a Federal District Court review of an ALJ decision if the ALJ hearing and/or MAC review is unfavorable to the member, in whole or in part, and the amount remaining in The language block is a graphic block of text that informs readers, in multiple languages,* how they can get help with understanding the information in a particular document at no cost to them. The Language Line is a service that connects human interpreters via telephone to individuals who wish to speak to each other but do not share a common language. The telephone interpreter converts the spoken language from one language to another, enabling listeners and speakers to understand each other. The fourth level of the appeal process, which involves a board authorized to review a request from any party including a member or UCare in which there is a dispute of the ALJ’s adverse decision or dismissal of the Any decision made by or on behalf of UCare regarding payment or services to which a member believes he or she is entitled. An organization determination as defined by 42 CFR §422.566(b) is any determination made with respect to any of the following: • Payment for temporary out-of-area renal dialysis services, emergency services, post-stabilization care, or urgently needed services. • Payment for any other health services furnished by a provider other than UCare that the member believes are covered under Medicare, or if not covered under Medicare should have been furnished, arranged for, or reimbursed by UCare. • UCare’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the member believes should be furnished or arranged for by UCare. • Discontinuation of a service if the member believes that continuation of the service is medically necessary. • Failure of UCare to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the member with timely notice of an adverse determination, such that a delay would adversely affect the health of the member. A health care professional other than a physician who is authorized under State law or other applicable law to An organization comprised of practicing doctors and other health care experts under contract to the federal government to monitor and improve the care given to Medicare members. A QIO reviews complaints raised by members about the quality of care provided by physicians, inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities (SNFs), home health agencies, Medicare health plans, and ambulatory surgical centers. The QIOs also review continued stay denials in acute inpatient hospital facilities as
  • 18. Concerns involving situations where the reporter indicated that the quality of clinical care or quality of service adversely affected, or has the potential to adversely affect, a member’s health or well-being. See Policy QAG005 for full definition of Quality of Care. The following are examples of potential QOC issues that could be reported to UCare Quality Management (QM) for additional investigation: • Provider skill or knowledge (procedural error, post-procedural complication, clinical knowledge, treating or diagnosing outside the scope of practice, provider behavior or communication, etc.). • Evaluation/Assessment (incomplete exam or a problem with the quality of the exam, diagnostic work-up not complete, delay in referring or scheduling surgery or procedure/test, delay in diagnosis, incorrect diagnosis, etc.). • Treatment (inappropriate or incorrect treatment, delay in treatment, failure to treat, ineffective or incomplete treatment, etc.). • Coordination/Continuity of care (delay or failure in provider follow-up, failure to seek consultation or second opinion, premature discharge from hospital or facility, lack of communication in response to problems identified by other providers, access to care, multiple providers and lack of communication or coordination, etc.). • General care (perceived poor care, inadequate staff skills to provide care needed, care not provided as ordered or prescribed, safety or environmental issues in care facility, incomplete or incorrect nursing or ancillary assessment, etc.). • Medical equipment (equipment malfunction leading to member harm, equipment not available for care, equipment not appropriate for member needs, improper use of equipment leading to patient harm, etc.). The second level of the appeal process, which involves the IRE's review of an adverse redetermination decision, the evidence and findings upon which it was based, and any other evidence the member submits or the IRE The first level of the appeal process, which requires UCare to review an adverse coverage determination decision, the findings upon which it was based, and any other evidence submitted or obtained. An individual appointed by a member or other party, or authorized under state or other applicable law, to act on behalf of a member or other party involved in an appeal or grievance. Unless otherwise stated, the representative has all of the rights and responsibilities of a member or party in obtaining an organization determination, filing a grievance, or in dealing with any of the levels of the appeals process, subject to the A written request from a member or representative asking UCare to reconsider an adverse organization determination made by UCare or a delegated entity.
  • 19. QAG-0003 QAG-0005 QAG-0006 QAG-0007 QAG-0008 3 5 6 7 8 3 5 6 3 5 6 5 6 5 6 7 8 7 3 5 6
  • 20. 5 6 5 5 5 3 6 7 5 6
  • 21. 3 5 5 6 7 8 5 3 5 6 7 5 6 7 8
  • 22. QAG-0009 QAG-0010 QAG-0012 QAG-0013 QAG-0014
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  • 25. QAG-0015 QAG-0019 QAG-0022 QAG-0023 QAG-0024
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  • 28. QAG-0025 QAG-0026 QAG-0027 QAG-0028 QAG-0029
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  • 34. Aging Report Run daily; Monday an enhanced copy is sent Coordinators will reply with a case status, which will be added to column A. There are macros built into the document that help step you through the process. Click Here for Aging Report Timeliness Report Run around the 15th of the month. Jill will send the source document in a spreadsheet for you. Click on "Blank Timeliness Report." You will also want to upload a copy of the source document that Jill sends you in this shared point site Click here for Timeliness Report CTM Report Also run around the 15 of the month. Information is extracted from CTM for this report. Click on "copy of ctm report" file. You will need to click on the open tab and re-select open and click the closed tab and re-select close, then fill in all yellow sections of the report Click here tor CTM Report