Appeals and Grievances

The following procedures for Appeals and Grievances are endorsed by CMS and must be followed by the plan in identifying, tracking, resolving and reporting all activity related to either an appeal or a grievance.

• Who can file an Appeal?
  An appeal may be filed by any of the following:
  • A member, including the member’s authorized representative,
  • A member’s physician, an ancillary provider or a hospital representing the member, or
  • A legal representative of the deceased’s estate.
• What is an Appeal?
  An appeal is a special kind of complaint you can make if KelseyCare Advantage refuses to cover something you think should be covered. If you have a complaint about health services that are not paid for, or not allowed, or stopped too soon, you can file an appeal.
• When can an Appeal be filed?
  A member has sixty (60) days to file an appeal regarding medical care:
  • That has not been approved,
  • That is being discontinued or reduced, or
  • That would pay or not pay for services already furnished.

  • Make a standard appeal in writing by submitting a signed request. A standard appeal must be received in writing. A "fast" or expedited appeal is accepted in writing, in person or over the telephone.

• Where can an appeal be filed?
  An appeal may be filed with the health plan. All employees and affiliates of a health plan are required to know where to direct member appeals.
• Why file an appeal?
  A member may file an appeal when an adverse decision is made that they want overturned, as well as to protect their rights.

  Fast Decisions / Expedited Appeals

  A member may request a decision be decided more quickly. The health plan must first determine if the appeal meets the following criteria for expedited appeals:

  • If the standard process and timeliness could jeopardize the life of health of the member, or
  • The likelihood of member’s ability to regain maximum function is reduced.

• Who can file a Grievance?
  
  • A member, including the member’s authorized representative,
  • A member’s physician, an ancillary provider or a hospital representing the member, or
  • A legal representative of the deceased’s estate.
• What is a Grievance?
  A grievance is dissatisfaction with any aspect of the Health Plan that does not involve an organizational determination - the approval or denial of services - by the Health Plan.
• When can a Grievance be filed?
  A member may file a grievance at any time. The grievance may be verbal or written.
• Expedited Grievance
  A member may request a fast review or expedited grievance if he or she disagrees with the Health Plan’s decision not to process the request for an expedited organization determination or an expedited reconsideration.
• Where can the Grievance be filed?
  A grievance may be filed with the Health Plan. All employees and affiliates of the Health Plan are required to know where to direct member grievances.
• Why file a Grievance?
  A grievance may be filed anytime a member is dissatisfied with any aspect of the health plan.

If you have a grievance, we encourage you to first call Member Services. We will try to resolve any complaint that you might have over the phone.

If you wish to send a formal written grievance, mail the grievance to:

P.O. Box 300427, Houston, Texas 77230

OR, fax to 713-442-9536

Be sure to include the following:

• Full name
• Address
• ID number
• Signature
• Date
• Summary of the problem
• Statement of action you are requesting

For more information about our Exceptions, Appeals and Grievances policies and procedures please contact Member Services.

All requests for exceptions, appeals and grievance data can also be directed to the Member Services number listed above.