Appeals and Grievances Procedures (updated Oct. 1, 2010)
Policy:
NetCare is required by Guam law to offer certain appeal and grievance procedures. These procedures are listed below. NetCare does have the option to impose time limitations on filing the appeals or grievances. These specific plan limitations, as well as any other plan specific information, are listed below.
Process:
Plan members have two (2) separate appeal routes. One takes place when the member contests a decision to deny or limit health care services "non-certification decision" or for experimental or investigational treatment. This is called an APPEAL. The other appeal route occurs when a member is unhappy with other aspects of the plan’s operations. A complaint about other operations of the plan is called a GRIEVANCE.
Members have the right to two (2) levels of review, for both appeals and grievances. The first level of review has a different name and a slightly different process depending on whether it is a first-level appeal or first-level grievance review. However, the second-level review is the same regardless of whether the dispute is a denial of services or another problem with the plan’s operation. This is referred to as a second-level grievance hearing or an external hearing.
Members who contest non-certification decisions (denials of services or procedures) have a right to ask for expedited review if the normal time limits could hurt the person’s health. Otherwise, the normal time limits apply. There is not an expedited process for first-level grievance decisions, because first-level grievance hearings do not deal with non-certification decisions (these are handled at the first level appeals).
Informal Reconsideration: NetCare has an informal process where it can resolve disputes quickly. The informal process is voluntary.
Appeal
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First Level Appeal: Members can file an appeal on their own behalf. In addition, a physician or other person acting on the member’s behalf can file an appeal. NetCare offers at least two levels of appeals. A physician who was not involved in the original decision must hear the first appeal. In this level, normally the physician has thirty (30) days for post-service claims or fifteen (15) days for pre-service claims to decide and inform the member of its decision of the appeal. All appeals from a member or physician acting on behalf of a member must be made in writing.
NetCare must provide a written decision to the member and the member’s provider. The decision should contain the qualifications of the person reviewing the appeal, the reviewer’s decision including the medical rationale and evidence used as the basis for the decision, and instructions on how to file a second-level grievance hearing.
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First Level Expedited Appeal: Members can request an expedited appeal if their health would be harmed by the 30-day or 15-day delay. In an expedited appeal, the physician has up to thirty-six (36) hours to make a decision. However, members can request the decision be made immediately if there is a more immediate health care need. Members will have their health services covered until the member is notified of the expedited review decision, if the appeal involves concurrent review such as continued stay in a hospital. Members are not entitled to expedited review if the health care services have already been provided and the issue is whether the care was appropriate.
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Second Level Expedited Appeal: Members can request an expedited second-level review if their health could be harmed because of any time delays. Members may request an expedited second-level review even if the first-level appeal or grievance review was not expedited. In this level review, the Plan has thirty-six (36) hours to make a decision. If necessary, NetCare may conduct the hearing over the phone or through submission of written information.
Grievance
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First Level Grievance Hearing: The member, his representative or the provider may submit a first-level grievance. NetCare must provide the member with information on how to submit written materials, within seven (7) business days after receiving notice of the grievance. The person reviewing the grievance cannot be the same person who initially handled the grievance. If the issue is a clinical one, at least one of the reviewers must be a medical physician with appropriate expertise. NetCare must make a grievance decision within thirty (30) days after receiving the complaint. The notice of the decision must include the same information as provided in first-level appeal decisions.
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Second Level (External) Hearing: NetCare also has second-level grievance reviews for members who are dissatisfied with the decision of the non-certification appeal or first level grievance review. NetCare must notify the member of the name and telephone number of the grievance coordinator, as well as information about the second-level grievance process within five (5) business days of receiving a request for a second-level grievance. Members have more extensive due-process rights at the second-level grievance review.
The member may request for an external review where NetCare will convene a hearing panel that will comprise of people who are not employees of NetCare or utilization review organization, who were not previously involved in the decision, and who do not have a financial interest in the outcome of the review. All people reviewing a second-level appeal involving a non-certification or clinical decision should be providers who have appropriate expertise in the health issue in dispute. If the review involves a grievance, the people should be members of the community who have appropriate expertise in the issue in dispute.
The member can attend the second-level grievance-hearing, request and receive all information relevant to the case in order to prepare for the hearing. Members may present his or her case to the review panel, submit supporting materials before and at the review meeting, ask questions of any member of the review panel and bring another person to help in the review hearing. These could include a family member, employer representative or attorney. If the member chooses to bring an attorney, then an attorney may also represent NetCare. The review panel has up to fifteen (15) business days to hold the hearing, and up to ten (10) business days thereafter to make a decision. This decision is a recommended decision to NetCare.
NetCare may provide expedited access or process of the external hearing if the member’s health or issue will be harmed by the thirty (30) day time delay. Expedited access to the External hearing level will follow the same process as the Expedited Appeal.
NetCare must provide a written decision to the member and the person’s provider (if appropriate). The decision should contain the qualifications of the people reviewing the grievance, the reviewer’s decision, including the medical rationale for the decision and the evidence used as the basis for the decision. The account states that the decision is the insurer’s final determination in the matter.
Appeals and Grievances Procedures (PDF version)
Grievance Complaint Form
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