Coverage decisions, appeals & grievances
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Coverage decisions, appeals and grievances
Coverage Decisions
A coverage decision is a decision we make about your medical care or prescription drug benefits and coverage or about the amount we will pay for your medical care services or prescription drugs.
Appeals
An appeal is a formal way of asking us to review and change a coverage decision we have made.
Grievances
A grievance is a complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage decisions or appeals.
Detailed information about Coverage Decisions, Appeals and Grievances can be found in the Evidence of Coverage.
You are entitled to obtain an aggregate number of grievances, appeals, and exceptions filed with Aspire Health Plan. You may do so by calling our Member Services number at 855-570-1600. Hours are 8 a.m. to 8 p.m. PT M – F from 4/1 – 9/30, 8 a.m. – 8 p.m. PT 7 days a week from 10/1 – 3/31 (except certain holidays).
Appointment of Representative Form
You have the right to appoint a person to file a coverage decision, appeal or grievance for you. You will need to fill out an Appointment of Representative Form PDF. The form should be signed by both you and the individual you would like to represent you. Once you have completed the form, you must submit that form via fax for mail to the applicable fax number or address listed above before we can talk to your representative.
You should know:
- This form only allows your representative to assist you with initial coverage requests, grievances or appeals.
- Your doctor can make a coverage request and file certain appeals without being your representative.
- This form is only valid for one year
- You have the right to revoke this document at any time
Appointment of Representative information PDF | Nombramiento de un Representante Spanish (en español PDF)
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Grievances
A Grievance must be made within 60 calendar days after you had the problem you want to complain about.
There are different time frames for Grievance review and decisions:
- Standard Grievance: A decision must be made as quickly as your health requires, but no later than 30 calendar days after receiving the request. Aspire Health Plan can extend the time by 14 days, if it is in your best interest. You will receive a letter notifying you of the results of the grievance or of an extension.
- Expedited “fast” Grievance: If the grievance is because a request for a “fast coverage decision” or a “fast appeal,” was denied, Aspire Health Plan will automatically make it a “fast” grievance. A “fast” grievance will be decided within 24 hours. Aspire Health Plan can extend the time by 14 days, if it is in your best interest. You will receive a telephone call first and then a letter notifying you of the results of the grievance or of an extension.
To file a Grievance or to check on the status of an in-process grievance, you may contact us:
Grievances
Call
(831) 574-4938 (local TTY:711)
(855) 570-1600 (toll free TTY:711)
Calls to these numbers are free.Hours of operation are:
8 a.m. to 8 p.m., 7 days a weekMEDICARE: You can submit a complaint directly to Medicare or call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.
You can also use some of Medicare’s standard forms in lieu of forms we have provided on this web site.
Fax
(831) 920-5903 (local)
(855) 519-5769 (toll free)Write
Aspire Health Plan Attn:
Appeals and Grievance Department
10 Ragsdale Dr, Suite 101
Monterey, CA 93940Forms
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Medical care appeals
A Medical Care (Part C) Appeal must be requested within 60 calendar days from the date on the Medical Care Coverage Decision notice. If you have a good reason for missing this deadline, we may give you more time. Examples of good cause may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.
There are two different types of Medical Care (Part C) Appeals.
- Claim payment Medical Care (Part C) Appeal – an appeal made for payment when a Medical Care Coverage Decision has been made to fully or partially deny a medical care claim.
- Pre-Service Medical Care (Part C) Appeal – an appeal made for coverage when a Medical Care Coverage Decision has been made to fully or partially deny coverage for a medical care procedure or treatment.
There are different time frames for Medical Care (Part C) Appeals reviews and decisions:
- Standard claim payment Medical Care (Part C) Appeal: A decision must be made no later than 60 calendar days after receiving the request. You will receive a letter informing you of the results of the review.
- Standard pre-service Medical Care (Part C) Appeal: A decision must be made as quickly as your health requires, but no later than 30 calendar days after receiving the request. You and your provider will receive a letter about the results of the review. Aspire Health Plan can extend the decision by up to 14 calendar days, if more information is needed and it will benefit you to extend the time frame. You will be sent a letter informing you of the extension and your right to file an expedited grievance. You and your provider will also receive a letter informing you of the results of the review.
- Expedited “fast” pre-service Medical Care (Part C) Appeal: This is an appeal that has to be decided quickly (within 72 hours) because a standard appeal could seriously put your life or health in danger, or prevent you from regaining the greatest function. Aspire Health Plan can extend the decision by up to 14 calendar days, if more information is needed and it will benefit you to extend the time frame. You and your provider will receive a letter about the extension and the right to file an expedited grievance. You and your provider will also receive a phone call about the decision as well as a letter outlining the results of the review. If a service was already received and only a claim payment is being appealed, a “fast” review cannot be given.
Medicare Part B Prescription Drugs: If you are appealing the denial of coverage for injectable drugs administered in a physician’s office or via home infusion and certain vaccinations, or for the denial of diabetic testing supplies, then your case will be handled as a Part B Appeal. Please see Chapter 4 of your Evidence of Coverage document for a list of drugs that are covered under Part B.
There are different timelines for Part B Appeal reviews and decisions:
- Standard Part B Drug: A decision can be made as quickly as your health requires, but no later than 7 calendar days after receiving the request. Please note that for this type of appeal, Aspire Health Plan cannot take extra time to make a decision for a Medicare Part B drug.
- Expedited Part B Drug: This is an appeal that has to be decided quickly, within 72-hours after receiving the request. Please note that for this type of appeal, Aspire Health Plan cannot take extra time to make a decision for a Medicare Part B drug.
To request a Medical Care (Part C) or Part B Prescription Drug Appeal or to check on the status of an in-process appeal, you may contact us:
Medical care appeals
Call
(831) 574-4938 (local)
(855) 570-1600 (toll free)
Calls to these numbers are free.Hours of operation are:
8 a.m. to 8 p.m., 7 days a weekTTY
(831) 574-4940 (local)
(855) 332-7195 (toll free)
Calls to these numbers are free.Hours of operation are:
8 a.m. to 8 p.m., 7 days a weekFax
(831) 920-5903Write
Aspire Health Plan Attn:
Appeals and Grievance Department
10 Ragsdale Drive, Suite 101
Monterey, CA 93940Forms
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Medical care coverage decisions
A medical care coverage decision is a decision we make about your benefits and coverage or about the amount we pay for your medical services. For more information on asking coverage decisions about your medical care, see chapter 9 of the Evidence of Coverage (what to do if you have a problem or complaint (coverage, decisions, complaints)). You may call us if you have questions about our coverage decisions process.
To request a Medical Care Coverage Decision or to check on the status of an in-process decision, you may contact us:
Medical Care Coverage Decisions
Call
(831) 574-4938 (local)
(855) 570-1600 (toll free).
Calls to these numbers are free.Hours of operation are:
8 a.m. to 8 p.m., 7 days a weekTTY
(831) 574-4940 (local TTY)
(855) 382-7195 (toll free TTY)8 a.m. to 8 p.m., 7 days a week
Fax
(831) 574-4939 (local)
(855) 519-5769 (toll free)Write
Aspire Health Plan Attn:
Appeals and Grievance Department
10 Ragsdale Drive, Suite 101
Monterey, CA 93940 -
Other help is available
MEDICARE: You can submit a complaint directly to Medicare or call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.
You can also use some of Medicare’s standard forms in lieu of forms we have provided on this web site.
QUALITY IMPROVEMENT ORGANIZATION: A Quality Improvement Organization (QIO) is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients.
You may contact the QIO, Livanta, in any of these situations:
- You have a grievance about the quality of care you have received.
- You think coverage for your hospital stay is ending too soon.
- You think coverage for your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.
LIVANTA
Call
(877) 588-1123 about hospital stay, home health care, skilled nursing facility care or Comprehensive Outpatient Rehabilitation Facility (CORF) services and quality of care grievances.7 days a week, 24 hours a day
TTY
(855) 887-6668
7 days a week, 24 hours a dayWrite
Livanta LLC
BFCC-QIO
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701-1105Website
Reports on Appeals and Grievances
To obtain reports on the aggregate number of appeals, grievances, and exceptions filed with Aspire Health Plan, please contact Customer Service. Following is Information on how to reach Customer Service.
Call:
(831) 574-4938 (local)
(855) 570-1600 (toll free)
TTY:
(831) 574-4940 (local TTY)
(855) 382-7195 (toll free TTY)Address:
Aspire Health Plan
10 Ragsdale Dr, Suite 101
Monterey, CA 93940 -
Prescription drug appeals
A Prescription Drug Appeal must be requested within 60 calendar days from the date on the Prescription Drug Coverage Decision notice. If you have a good reason for missing this deadline, we may give you more time. Examples of good cause may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.
There are different time frames for Prescription Drug Appeals reviews and decisions:
- Standard Prescription Drug Appeal: Aspire Health Plan must make a decision as quickly as your health requires, but no later than 7 calendar days after receiving the request. You will receive written notification of the decision. If a decision could not be made within 7 days, the appeal will automatically be sent within 24 hours to an Independent Review Entity for their review and decision.
- Expedited “Fast” Prescription Drug Appeal: This is an appeal that has to be decided quickly, within 72 hours of receiving the request. This is used when a standard appeal could seriously put your life or health in danger, or prevent you from regaining the greatest function. A provider is the most suitable person to decide if a “fast” rather than a standard review is appropriate. If a decision could not be made within 72 hours, the appeal will automatically be sent within 24 hours to an Independent Review Entity for their review and decision. An appeal will not be expedited if you already received the drug and are asking to be paid back.
To request a Prescription Drug Appeal or to check on the status of an in-process appeal, you may contact us:
Prescription drug appeals
Call
(888) 495-3160 (toll free)
Calls to this number are free.
This is a 24 hour line.TTY 711
Calls to this number are free.
This is a 24 hour line.Fax
(858) 790-6060Write:
MEDIMPACT HEALTHCARE SYSTEMS,
ATTN: PRIOR AUTHORIZATION;
10181 SCRIPPS GATEWAY CT.,
SAN DIEGO, CA 92131Forms:
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Prescription drug coverage decisions and exceptions
You can ask Aspire Health Plan to make a coverage decision or “exception” to our coverage rules. There are several types of exceptions that you can ask us to make.
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Aspire Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
- You can ask us to provide a higher level of coverage for your drug. For example, if your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier subject to the tiering exceptions process instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier.
Generally, Aspire Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement.
You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.
To request a Prescription Drug Coverage Decision or Exception or to check on the status of an in-process decision, you may contact us:
Prescription Drug coverage decisions and exceptions
Call
(888) 495-3160 (toll free)
Calls to this number are free.
This is a 24 hour line.TTY 711
Calls to this number are free.
This is a 24 hour line.Fax
(858) 790-7100Write
MEDIMPACT HEALTHCARE SYSTEMS,
ATTN: PRIOR AUTHORIZATION;
10181 SCRIPPS GATEWAY CT.,
SAN DIEGO, CA 92131Online
