Appeals and Grievances

A coverage decision is any decision made by the plan regarding:

• Receipt of, or payment for, a care item or service
• The amount you pay for an item or service
• A limit on the quantity of items or services

Any time that we make a decision about what we will cover and how much we will pay for your medical services or drugs, we are making a coverage decision.

As a member of Advantage MD, you have a right to request a coverage decision. If the plan denies coverage for your requested item or service, you have the right to appeal and ask us to reconsider the decision. You also have a right to file a grievance (also called a complaint) about the health plan.

To request a coverage decision regarding medical care you or your representative may:

Call:

We are available October 1 through March 31, Monday through Sunday 8 a.m. to 8 p.m., and April 1 through September 30, Monday through Friday 8 a.m. to 8 p.m.

PPO members: 877-293-5325 (TTY: 711)
HMO members: 877-293-4998 (TTY: 711)

Fax:

855-206-9203

Write:

Johns Hopkins Advantage MD, PO BOX 3538, Scranton, PA 18505

To request a coverage decision regarding payment requests you or your representative may:

Call:

We are available October 1 through March 31, Monday through Sunday 8 a.m. to 8 p.m., and April 1 through September 30, Monday through Friday 8 a.m. to 8 p.m.

PPO members: 877-293-5325 (TTY: 711)
HMO members: 877-293-4998 (TTY: 711)

Fax:

855-206-9203

Write:

Johns Hopkins Advantage MD, PO BOX 3537, Scranton, PA 18505

If we make a coverage decision that you are not satisfied with, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a decision we have made.

You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for coverage decision. For specific instructions on how to file an appeal, you or your representative may:

Call:

PPO members: 877-293-5325 (TTY: 711)
HMO members: 877-293-4998 (TTY: 711)

Write:

NEW: Johns Hopkins Advantage MD Appeals, P.O. Box 8777, Elkridge, MD 21075

Fax:

NEW: 410-424-2806

All appeals requests must include a completed and signed Waiver of Liability Form.

If you have questions about the appeals process or would like to know the status of an appeal you’ve filed, please call us. We are available October 1 through March 31, Monday through Sunday 8 a.m. to 8 p.m., and April 1 through September 30, Monday through Friday, 8 a.m. to 8 p.m.

When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we review the coverage decision we made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision. Under certain circumstances, which we discuss later, you can request an expedited or “fast coverage decision” or fast appeal of a coverage decision.

If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to us. (In some situations, your case will be automatically sent to the independent organization for a Level 2 Appeal. If this happens, we will let you know. In other situations, you will need to ask for a Level 2 Appeal). If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.

If we are using standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. For post service appeals (appeals about coverage have already received), we must give you our answer within 60 calendar days after we receive your appeal. We will give you our decision sooner if your health condition requires us to.

However, if you ask for more time, or we need to gather more information that may benefit you, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you in writing.

If we do not give you an answer by the deadline above (or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization.

The formal name for “making a complaint” is “filing a grievance.” A grievance is a type of complaint you make about the health plan or one of our network providers, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

You or your appointed legal representative may file a grievance. You may name a relative, friend, attorney, doctor or someone else to act for you. Others may already be authorized under state law to act for you. You may download the appointment of representative form.

• Appointment of Representative form

Contact us promptly either by phone or in writing. Your complaint must be filed within 60 days of the event or incident.

You can file a grievance with us by mail, fax, or telephone.

Call:

We are available October 1 through March 31, Monday through Sunday 8 a.m. to 8 p.m., and April 1 through September 30, Monday through Friday 8 a.m. to 8 p.m.

PPO members: 877-293-5325 (TTY: 711)
HMO members: 877-293-4998 (TTY: 711)

If there is anything else you need to do, we will let you know.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and mail it to us.

Write:

Johns Hopkins Advantage MD Appeals and Grievances, P.O. Box 3507, Scranton, PA 18505

Fax:

855-825-7726

You also have the right to ask for an expedited (fast) grievance. Any fast grievance must be resolved within 24 hours from the time you contact us. You have the right to request a fast grievance if you disagree with:

• The 14-day extension on “fast coverage decision” or “fast appeal”; or
• Our denial of your request to expedite a coverage decision or reconsideration for health services.

Upon receipt of the grievance, we will promptly investigate the issue you have identified. If we agree with your grievance, then we will cancel the 14-day extension and expedite the determination or appeal as you originally requested. Regardless of whether we agree or not, we will notify you of our decision by phone within 24 hours and will send you written follow up.

If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal” we will automatically give you a “fast” complaint. If you have a “fast complaint” it means we will give you an answer within 24 hours.

After you file your complaint, we will investigate it. For all grievances, you will receive a written notice stating the results of the review. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your grievance. We must respond whether we agree with your complaint or not. We may extend the time frame by up to 14 days if you ask for an extension, or if we identify a need for additional information and the delay is in your best interest. Most complaints are answered within 30 days.

You can only end your membership with Johns Hopkins Advantage MD during certain times of the year. Those include:

• The Annual Enrollment Period (AEP), which happens from October 15 to December 7. If you do so, your membership will end when your new plan’s coverage begins on January 1.
• The Medicare Advantage Open Enrollment period is from January 1 to March 31. During this time you have the opportunity to:
  • Switch to a different Medicare Advantage plan
  • Return to Original Medicare

  If you choose to switch to Original Medicare during this period, you have until March 31 to join a separate Medicare prescription drug plan to add drug coverage. Your membership will end on the first day of the month after we get your request to switch to Original Medicare. If you also choose to enroll in a Medicare prescription drug plan, your membership in the drug plan will begin the first day of the month after the drug plan gets your enrollment request.

• In certain situations, members of Johns Hopkins Advantage MD may be eligible to end their membership at other times of the year if they qualify for a Special Enrollment Period (SEP). To see a full list of examples of situations that meet the criteria for the Special Enrollment period, visit medicare.gov. To find out if you are eligible for a Special Enrollment Period, please call Medicare at 800-MEDICARE (800-633-4227), 24 hours a day, 7 days a week. TTY users call 877-486-2048.

If you have questions about ending your membership with Johns Hopkins Advantage MD, please call us .

PPO members: 877-293-5325 (TTY: 711)
HMO members: 877-293-4998 (TTY: 711)

You can also contact Medicare at 800-MEDICARE (800-633-4227), 24 hours a day, seven days a week. TTY users should call 877-486-2048.