In October of 1999, the House of Representatives passed a bipartisan patient protection bill that dramatically expanded a patient's right to sue a health plan if injured as a result of a denial of care or a delayed benefit coverage. MCOs that offer any type of senior plans have always had an external appeal option available to their members as part of Medicare. The center is charged with filing, making determinations and tracking appeals involving Medicare beneficiaries. The NCQA evaluates a number of factors regarding members' rights and responsibilities during the accreditation process, such as how clearly the MCO informs its members about how to get care and use its services, and how well the organization responds to members' complaints and appeals. The following discussion is greatly simplified to illustrate how a managed care complaint and appeals process works, not just for senior plans, but for managed care members in general.
Complaints are the first level of entry into the appeals process.
Once a determination is made, the member is notified of the findings and the benefit is either paid or denied. If the benefit is denied, instructions are provided in the letter to the member regarding the appeal process. A determination is made after reviewing the provider's response, medical records and progress notes, and facility and community standards for similar issues. The member is notified of the determination, and the case is deemed resolved. As mentioned earlier, when the member receives a denial or unfavorable determination, appeal instructions are included.