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Appeals and Grievances

What is an appeal?

If you are unhappy with our organization determination for medical care coverage or our coverage determination for prescription drug coverage, you can submit an appeal.

An appeal is a formal way of asking us to review and change our organization determination or coverage determination. You would submit an appeal if you want us to reconsider and change a decision we have made about medical care or prescription drug benefits, or what we will pay for medical care or a prescription drug.

When you submit an appeal, we review the organization determination or coverage determination to see if we followed all of the rules properly. Your appeal is handled by different reviewers than those who made the organization determination or coverage determination. When we have completed the review we give you our decision.

  • An appeal regarding an organization determination is also called a reconsideration.
  • An appeal regarding a coverage determination is also called a redetermination.

For information on the total number of grievances, appeals or formulary exceptions submitted to Ochsner Health Plan, please email the request to appealsgrievancesohp@ochsner.org

How do you ask for an appeal?

You can ask for an appeal yourself, or your doctor or someone you have legally appointed to act on your behalf may do it for you. This person would be called your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you. If you want someone other than your doctor, you must complete the Appointment of Representative Form. When we reference “you” on this page, we mean you, your doctor or your appointed representative.

Appointment of Representative Form

Here’s a link to the “Appointment Of A Representative” form: https://www.ochsnerhealthplan.com/sites/default/files/2022-02/Appointment%20of%20Representative.pdf

You may ask for either a “standard” appeal or a “fast” appeal. More information about standard appeals and fast appeals for medical coverage and prescription drug coverage is available on this page.

  • Standard appeals must be made in writing by submitting a signed request.
  • Fast appeals may be made in writing or by calling us.

You must submit your appeal request within 60 calendar days from the date on the letter we sent with our answer to your original request for an organization determination or coverage determination. If you miss the deadline and there is a good reason for missing it, we may give you more time to submit an appeal. Your first appeal is called a Level 1 Appeal.

What is the timeline for a standard Level 1 Appeal for Medical Care?
For a standard Level 1 Appeal, we will give you an answer as quickly as your health condition requires but no later than 30 calendar days after we receive your appeal if your appeal is about services you have not yet received. If your request is for a Medicare Part B prescription drug you have not yet received, we will give you our answer within 7 calendar days after we receive your appeal. We will give you an answer as quickly as your health condition requires but no later than 60 calendar days after we receive your appeal if your appeal is for reimbursement for medical care you have already received and paid for yourself.

However, if your appeal is about services you have not yet received and we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more calendar days to make our decision. We will let you know if we decide to do this. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. If you believe we should not take extra days, you can file a “fast” grievance, and we will give you an answer to your grievance within 24 hours.

If we do not give you our answer by the deadlines noted above, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal.

What happens after Ochsner Health Plan decides on a standard Level 1 Appeal for Medical Care?
If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 30 calendar days if your request is for a medical item or service, or within 7 calendar days if your request is for a Medicare Part B prescription drug.

If you requested us to pay you back for medical care you already received and our answer is “YES” to all or part of what you requested, we are required to send you payment within 60 calendar days after we receive your appeal.

If our answer is “NO” to all or part of what you requested, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal.

What are the requirements and timeline for a fast Level 1 Appeal for Medical Care?
If your health requires it, you can ask us for a “fast” appeal. To get a fast appeal, you must meet two requirements:

  • You must be appealing a decision we made about coverage for medical care you have not yet received. You cannot ask for a fast appeal if your request is about medical care you have already received.
  • Using the standard deadlines could cause serious harm to your health or hurt your ability to function.


If your doctor tells us that your health requires a fast appeal, we will automatically give you a fast appeal.

If you ask for a fast appeal on your own without your doctor’s support, we will decide whether your health requires that we give you a fast appeal. If we decide your medical condition does not meet the requirements for a fast appeal, we will process your request as a standard appeal and notify you of our decision to process your request as a standard appeal by sending you a letter. Our letter will indicate that we will automatically give you a fast appeal if your doctor requests it. You will also be provided with information about your right to file a “fast” grievance about our decision to give you a standard appeal instead of a fast appeal.

For a fast Level 1 Appeal, we will give you an answer as quickly as your health condition requires but no later than 72 hours after we receive your appeal. However, if we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more calendar days to make our decision. We will let you know if we decide to do this. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. If we do not give you our answer within 72 hours (or, if there was an extended review period, by the end of that period), we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal.

What happens after Ochsner Health Plan decides on a fast Level 1 Appeal for Medical Care?
If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 72 hours after we receive your appeal.

If our answer is “NO” to part or all of what you requested, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal

What happens with a Level 2 Appeal for Medical Care?

The Independent Review Organization will review your appeal. This organization is hired by Medicare and is not connected with Ochsner Health Plan. We send the information about your appeal to the organization. You have the right to provide the organization with additional information to support your appeal.

If you had a standard Level 1 Appeal, you will have a standard Level 2 Appeal.

  • The organization must give you an answer within 30 calendar days of when it receives your appeal. If your request is for a Medicare Part B prescription drug, the review organization must give you an answer to your Level 2 Appeal within 7 calendar days of when it receives your appeal.
  • If the organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The Independent Review Organization can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug.

If you had a fast Level 1 Appeal, you will have a fast Level 2 Appeal.

  • The organization must give you an answer within 72 hours of when it receives your appeal.
  • If the organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The Independent Review Organization can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug.


What happens after the Independent Review Organization decides on a Level 2 Appeal for Medical Care?
If the organization’s answer is “YES” to all or part of what you requested for a standard appeal, we must authorize the coverage within 72 hours or provide the service within 14 calendar days after we receive its decision; and if the organization’s answer is “YES” to all or part of what you requested for a fast appeal, we must authorize the coverage within 72 hours after we receive its decision. If the organization’s answer is “YES” to all or part of a standard appeal request for a Medicare Part B prescription drug, we must authorize or provide coverage within 72 hours after we receive its decision; and if the organization’s answer is “YES” to all or part of a fast appeal request for a Medicare Part B prescription drug, we must authorize or provide the coverage within 24 hours after we receive its decision.

If the organization’s answer is “YES” to your request about a payment we denied for medical services, we are required to send the payment you requested within 30 calendar days to you or the provider.

If the organization’s answer is “NO” to part or all of what you requested, it means it agrees with us that your request or part of your request should not be approved. The organization will send you a letter that tells you the dollar value that must be in dispute for you to continue with the appeals process. If your case meets these requirements, you decide if you would like to continue the appeals process.

There are three additional levels to the appeals process after a Level 2 Appeal, for a total of five levels of appeal. There is also a separate appeals process if you would like us to cover a longer inpatient hospital stay or would like us to keep covering home health care, skilled nursing facility services or comprehensive outpatient rehabilitation facility services.

Grievances

What is a grievance?

A grievance is any complaint (other than an organization determination or coverage determination) related to your health plan or health care provider, including problems related to quality of care, waiting times and customer service, among others. A grievance is not used for requesting a coverage decision for benefits, coverage or payment. For example, you would file a grievance if you:

  • Are unhappy with the quality of care you have received
  • Believe your privacy was not respected
  • Are unhappy with or have experienced disrespect from a provider or our plan
  • Are having difficulties scheduling a doctor’s appointment
  • Are unhappy with the cleanliness or condition of a doctor’s office or network pharmacy
  • Believe our plan has not given you a notice you are required to receive or gave you information you believe was hard to understand

You can also file a complaint if you think our plan is not responding quickly enough to or meeting deadlines for a coverage decision or appeal request.

For information on the total number of grievances, appeals or formulary exceptions submitted, please email the request to appealsgrievancesohp@ochsner.org

How do you ask for a grievance?

We encourage you to first contact member services toll-free 1-833-674-2112 (TTY: 711)
seven days a week, from 8 a.m. to 8 p.m. if you are having one of these problems. We will try to resolve the grievance over the phone.

If you are not satisfied with our response or if we cannot resolve your grievance over the phone, or if you do not wish to call us, you may submit your grievance either via fax or mail using the fax number or mailing address provided in the next section.

Please note: Whether you call or write, you should contact member services right away. Most grievances must be made within 60 days of the problem or event.

You may also submit a grievance to Medicare through its online Medicare Complaint Form.

How does the grievance review process work?

The Ochsner Health Plan grievance review process is as follows:

  1. We must receive your grievance within 60 calendar days of the event or incident you are complaining about. If something kept you from filing your complaint (you were sick, we provided incorrect information, etc.) let us know and we might be able to accept your complaint past 60 days. We will address your complaint as quickly as possible but no later than 30 days after receiving it. Sometimes we need additional information, or you may wish to provide additional information. If that occurs, we may take an additional 14 days to respond to your complaint. If the additional 14 days is taken, you will receive a letter letting you know. If your complaint is because we took 14 extra days to respond to your request for a coverage determination or appeal or because we decided you didn’t need a fast coverage decision or a fast appeal, you can file a fast complaint. We will respond to you within 24 hours of receiving your complaint.
  2. If you are dissatisfied with the response to your grievance, you can request a review in writing. Your review request may include written information from you or any other party of interest. You must submit the review request within 60 calendar days of receiving the original resolution. Our appeals and grievances coordinators will direct your review request to the appropriate committee, which will reconsider your written grievance and respond to you in writing within 30 calendar days of receipt of your request for review. The plan can present your case to the committee on your behalf, or you may choose to present your case to the committee yourself.

If you are filing a grievance because we denied your request for a “fast” decision on an organization determination or coverage determination or a “fast” appeal, we will automatically give you a “fast” grievance. This means we will give you an answer to your grievance within 24 hours.

When you file a grievance, we will answer you right away if possible. Most grievances are answered within 30 calendar days. If we need more information and the delay is in your best interest, or if you ask for more time, we can take up to 14 more calendar days (44 days total) to answer your grievance. If we decide to take extra days, we will tell you in writing.

Contact Information

For Appeals for Medical Care
Call:

Toll-free 1-866-978-2029(TTY: 711)
seven days a week, from 8 a.m. to 8 p.m.
Fax:
985-898-1505
Write:
Ochsner Health Plan
General Appeals
2100 Covington Centre
Covington, LA 70433
appealsgrievancesohp@ochsner.org

For Appeals for Prescription Drugs
Toll-free 1-800-910-1837 (TTY: 711)
seven days a week, from 8 a.m. to 8 p.m.
Fax:
858-790-6060
Write:
Part D Appeals Department
10181 Scripps Gateway Ct.
San Diego, CA 92131

For Grievances (Complaints) for Medical Care
Toll-free 1-833-674-2112 (TTY: 711)
seven days a week, from 8 a.m. to 8 p.m.
Fax:
504-754-6496
Ochsner Health Plan
PO Box 4376
Scranton, PA 18505
appealsgrievancesohp@ochsner.org

For Grievances (Complaints) for Prescription Drugs
Toll-free 1-800-910-1837 (TTY: 711)
seven days a week, from 8 a.m. to 8 p.m.
Fax:
504-754-6496
Write:
Ochsner Health Plan
PO Box 4376
Scranton, PA 18505
appealsgrievancesohp@ochsner.org