Appeals & Grievances

Something arrives and you have to say what it is before anything else can happen. A member calls because a service was denied. A member calls because she was on hold, then transferred, and no one ever called her back, which is a different thing entirely. A letter comes from a son about his father's care, and whether he is permitted to file at all depends on whether a valid appointment of representative is on file. A physician's office calls on a member's behalf about a service not yet delivered, which is a request for a determination rather than a challenge to one already made. A complaint the member filed through Medicare's own helpline reaches you from a federal system with a clock already running. The line that matters is whether the contact contests a coverage or payment decision the plan made, which makes it an appeal and carries a deadline, a required written decision and a further level of review the member is entitled to, or whether it is a complaint about anything else, access, service, staff conduct, timeliness, quality of care, which is a grievance with its own process and its own clock. Get it wrong in one direction and you have quietly removed a right the member had. Get it wrong in the other and you have built a formal case file around a bad phone call. Then you decide standard or expedited, because a member whose health could be seriously jeopardized by waiting is entitled to the faster track, and a treating physician saying so is enough to put them on it. And one contact is often two cases: the denial is an appeal, the way the denial was explained is a grievance, and both have to be opened.

Before anyone can decide an appeal, someone has to build the file. You go get the original determination and what it actually said, not the code in the system but the notice that went to the member. You establish which criteria were applied and which version of them was in force on the date the request was made, because criteria get updated and the one on your screen today may not be the one the case was decided under. You pull the clinical record, which usually means asking a provider's office for it and then waiting, and then reading through it for the part that matters, the conservative treatment that was tried and failed, the imaging, the note saying the member could not tolerate the alternative the criteria assume. You pull the member's own argument out of whatever form it arrived in, a handwritten letter, a call someone summarized, a treating physician's statement attached to a fax. Then you check that the file is complete, and complete means specific things: that the reviewer is clinically qualified for this question and was not involved in the original decision, that everything the member sent is in there, that the record covers the period actually in dispute. Cases that go past your own review to an outside entity travel as a file, and whatever you failed to put in it is the record someone else decides on.