Appeals & Grievances

Organization Determinations

A coverage decision is a decision we make about your benefits and coverage, or about the amount we will pay for your medical services. For example, your plan network doctor makes a coverage decision for you whenever you receive medical care from him or her, or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a certain medical service, or if your healthcare provider refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases, we might decide a service is not covered or is no longer covered by Medicare. If you disagree with any of our coverage decisions, you can make an appeal.

Medical Coverage Appeals

You have the right to appeal if the plan or medical group denies, reduces, or denies payment (claim denial) for a medical service you believe you are entitled to receive.

The Appeals Process

1. Level 1 — Plan Reconsideration

   Submit your appeal within 65 days of the denial notice. For pre-service appeals (before you receive the service), the plan responds within 30 days for standard requests, or 72 hours for expedited (fast) requests. For post-service appeals (after you've already received the service), the plan responds within 60 days.

2. Level 2 — Independent Review Entity (IRE)

   If the plan upholds the denial, appeal to C2C Innovative Solutions, Inc. — an independent organization hired by Medicare, not the plan.

3. Levels 3, 4, and 5

   Further appeals are available through an Administrative Law Judge, the Medicare Appeals Council, and Federal District Court, depending on the dollar amount involved.

How to submit a level 1 appeal:

• Phone: 1-800-838-8271, TTY: 711
• Fax: 1-626-380-9049
• Mail: Imperial Health Plan of California, Inc., Attn: Appeals & Grievances, PO Box 60874, Pasadena, CA 91116

If requested by a representative, there are additional steps necessary before the request can be processed (please see the AOR section).

Part D Drug Coverage Appeals

If you are denied coverage for a prescription drug, you have the right to request a redetermination (Level 1 Appeal). You have 65 days from the date of the denial notice to file. The plan will respond within 7 calendar days for standard coverage requests, 14 days for payment requests, or 72 hours for expedited (fast) requests.

If Level 1 is denied, you may continue to C2C Innovative Solutions, Inc. (IRE) for Level 2 review, and further levels after that.

How to submit a Part D appeal:

• Phone: 1-800-838-8271, TTY: 711
• Fax: 1-626-380-9049
• Mail: Imperial Health Plan of California, Inc., Attn: Appeals & Grievances, PO Box 60874, Pasadena, CA 91116

Grievances (Complaints)

A grievance is a complaint expressing dissatisfaction with the way Imperial Health Plan or our delegated entity provides health care services — anything other than a coverage decision, such as quality of care, wait times, provider behavior, or plan operations. You must file a grievance within 60 days from the date of the incident that precipitated the grievance.

Standard Grievances

The plan will respond within 30 calendar days of receiving your complaint.

Expedited (Fast) Grievances

You may request a fast grievance if the plan denied your request for a fast coverage decision or fast appeal, or if the plan requested additional time to resolve your complaint and you disagree. Fast grievances receive a response within 24 hours.

Part D Grievances

Complaints about a non-covered or excluded Part D drug may be filed as a standard grievance. The plan will respond within 30 calendar days.

Quality of Care Complaints — Quality Improvement Organization (QIO)

Important reminder: When your Grievance (complaint) is about quality of care, you also have additional options:

1. You can make your complaint to the Quality Improvement Organization (QIO). If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our Plan). Livanta is California's QIO and can be reached through the following:
   • Call: 1-877-588-1123 (TTY: 1-855-887-6668)
   • Write to: Livanta BFCC-QIO Program, 9090 Junction Drive, Suite 10, Annapolis Junction, MD 20701
2. Or if you wish, you can make your complaint about quality of care to our Plan and also to the Quality Improvement Organization, Livanta, following the same processes above.

How to file a grievance:

• Phone: 1-800-838-8271, TTY: 711
• Fax: 1-626-380-9049
• Mail: Imperial Health Plan of California, Inc., Attn: Appeals & Grievances, PO Box 60874, Pasadena, CA 91116
• Medicare directly: 1-800-MEDICARE (1-800-633-4227), TTY: 1-877-486-2048

You can also file a complaint about the plan by going directly to Medicare and calling 1-800-MEDICARE or going to Medicare.gov's complaint form. Additional information regarding the grievance process can be found on the Medicare website.

Appointment of Representative

If you would like another person to act on your behalf in an appeal or grievance, they must be named as your representative using the form below. The completed AOR form must be received before the plan can process the request.

Submit by fax to 1-626-380-9049 or mail to Imperial Health Plan of California, Inc., Attn: Appeals & Grievances, PO Box 60874, Pasadena, CA 91116.

Additional Medicare Resources

The following links will take you to external websites outside of imperialhealthplan.com. Imperial Health Plan is not responsible for the content or privacy practices of external sites.

• CMS: Coverage Determinations ↗
• CMS: Exceptions ↗
• CMS: Redeterminations ↗
• File a complaint with Medicare directly ↗

You can also contact Medicare at 1-800-MEDICARE (1-800-633-4227), TTY: 1-877-486-2048, available 24/7.