Scott & White Health Plan

Grievance, Appeals, and Exceptions

Grievances

A grievance is a type of complaint you make about us or one of our providers, including a complaint concerning the quality of your care. This type of complaint does not involve payment or coverage disputes.

In order to exercise this right, you must file your grievance no later than 60 days after the event or incident that precipitates the grievance. The plan will review your grievance and provide a formal response no later than 30 days from the date your grievance was received. Grievances can be received by our Customer Service Coordinators via mail, telephone, facsimile or in-person delivery (contact information is listed below).

Appeals

An appeal is any of the procedures that deal with:

• The review of a service denial made by the Prescription Drug Plan on the benefits under a Medicare Prescription Drug Plan the enrollee believes he or she is entitled to receive, or
• On any amounts the enrollee must pay for the drug coverage, or
• A type of complaint you make when you want us to reconsider and change a decision we have made about what services are covered for you or what we will pay for a service.

An appeal must be filed within 60 days from the date that the determination was rendered. The plan will review your request for appeal and formally respond to you no later than seven (7)days from the date your appeal was received. Appeals can be received by our Customer Service Coordinators via mail, telephone, facsimile or in-person delivery (contact information is listed below).

Exceptions

Enrollees will have the option to request exceptions to the plan's tiered cost-sharing structure. An exception is a type of coverage determination that, if approved, allows you to obtain a drug that is not on our formulary  (a formulary exception), or receive a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if we require you to try another drug before receiving the drug you are requesting, or the plan limits the quantity of dosage of the drug you are requesting (a formulary exception). To request an exception, members should complete the Coverage Determination Request Form  or you may submit a simple written document to request the exception. Providers can access the Medicare Part D Coverage Determination Request Form. . Members can access the Medicare Prescription Drug Determination Request Form . If the beneficiary is not the individual completing the coverage determination form, an Appointment of Representative form  must be completed and returned along with the request for coverage determination. Members and providers can fax, mail or deliver the form(s) to:

Scott & White Health Plan
Prescription Services
1206 West Campus Drive
Temple, TX 76502
Phone: 800-728-7947
TTY/TDD: 800-735-2898
Fax: 254-774-1623

For reconsideration of a previous Medicare Prescription Drug Denial, please complete the Request for Reconsideration of Medicare Prescription Drug Denial form  and mail or fax to:

MAXIMUS, Federal Services
Medicare Part D QIC
860 Cross Keys Office Park
Fairport, NY 14450

Expedited Re-determinations

An expedited appeal can be requested orally or in writing by the enrollee or a physician acting on behalf of the enrollee. If the plan determines that the request meets the expedited criteria, the plan will render a decision as expeditiously as your health condition requires but not exceeding 72 hours. If the request does not meet the expedited criteria then it will render a decision within the standard re-determination time frame of seven (7) days.

Questions, Concerns, or Problems

Scott & White Health Plan encourages you to let us know right away, if after becoming a member, you have questions, concerns, or problems related to your covered services or the care you receive. For assistance or to request an aggregate number of SeniorCare Rx (Cost) Plan grievances, appeals and exceptions, please contact a Customer Service Coordinator at the phone number listed below.

For complete details of our exceptions, appeals, and grievances procedures, please refer to [section 9] in your Evidence of Coverage , or call Scott & White Health Plan.

The above information is current as of October 2010.

"A Health Plan with a Medicare Contract"

H4564_SC_WEB_GRIEV_2011  CMS Approved 11/17/2010