Appeals and Grievances

Important Information About Your Appeal Rights

There are 2 kinds of appeals:

Standard Appeal – An appeal is the process to review a decision you may not like. The negative decision is called a coverage determination. If you do not like the choice we have made, you have the right to make an appeal. We will review our decision and let you know what we decide. You will get a written answer on a standard appeal 15 days after we hear your appeal (7 days for appeals related to medications).

We may take longer if you ask for more time, or if we need to know more about your case. We will tell you if we are taking extra time and will explain why more time is needed. 

If you had to pay for services and want to be paid back, you can ask us. If your appeal is to pay you back, we will tell you in writing. We will tell you in 15 days.

Fast Appeal – You will get an answer within 72 hours after we get your appeal.

You can ask for a fast appeal if you or your doctor think your health could be in danger.

If your doctor asks for a fast appeal, you will get one.
If you want a fast appeal but your doctor did not ask, we may not approve it. If we don’t give you a fast appeal, we’ll give you an answer within 15 days (or 7 days for drug appeals).

How to ask for an appeal with Buckeye.

Step 1:

To ask for an appeal you have to tell us. It can be from you, your representative, or your doctor.  Your appeal request must include:

  • Your name
  • Address
  • Member number
  • Reasons for appealing
  • Other information that shows why you need the item or service. Call your doctor if you need this information.

You can ask to see the medical records and other documents we used to make our decision before or during the appeal. At no cost to you, you can also ask for a copy of the guidelines we used to make our decision.

Step 2: Mail, fax, or deliver your appeal or call us.

Buckeye Health Plan – MyCare Ohio
ATTN: Medicare Operations
7700 Forsyth Blvd.
St. Louis, MO 63105
Phone: 1-866-549-8289
Fax: 1-844-273-2671

If you ask for an appeal by phone, we will send you a letter confirming what you told us.

State Hearing – You also have the right to ask for a state hearing with the Ohio Department of Medicaid, Bureau of State Hearings. Anytime you receive a notice of denial about a drug or medical service, the letter will include information about how you can file an appeal with Buckeye or a state hearing with the Ohio Department of Medicaid – fill out the state hearing form and mail it to State Hearings. You can also fax your hearing request to 1-614-728-9574. You can request a hearing within 90 days of the date on the initial denial letter/state hearing rights notice.

How to get a total Number of Grievances, Appeals and Exceptions Filed with Buckeye: To obtain a total number of Buckeye grievances, appeals and exceptions, please call Member Service number at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m., Monday through Friday. On weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.

For process or status questions, you can call Member Service number at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m., Monday through Friday. On weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.

How do non-contracted providers file a claim appeal?  

In accordance with the requirements established by the Centers for Medicare and Medicaid Services (CMS), non-contracted providers have Medicare appeal rights. Medicare appeal rights apply to any claim for which we have denied payment.

  • All requests for payment appeals must include a completed and signed “Waiver of Liability” (WOL) statement.
  • The appeals process cannot begin until a completed and signed WOL is received.
  • Requests for appeals that do not include a WOL, or for which a WOL is not received within the required timeframes, will be issued a Notice of Dismissal of Appeal Request.
  • Requests for payment appeals must be filed within 60 days of the explanation of payment (EOP).
  • A copy of the EOP and any other supporting documentation (such as medical records when applicable) must be submitted with the appeal request.
  • We will make a decision regarding the appeal within 60 days from the date the appeal request was received with the completed Waiver of Liability.

Non-Contracted Provider Appeal Requests should be submitted, with the completed WOL, to the following address:

Buckeye Health Plan – MyCare Ohio MMP
Grievance and Appeals- Medicare Operations
P.O. Box 4000
Farmington, MO 63640-3822   

 

What is a grievance?

A grievance is a complaint about anything other than benefits, coverage, or payment. You would file a grievance if you had any type of problem with the quality of your medical care, waiting times, or the customer service you receive. You would also file a grievance if you did not think we had responded quickly enough to your request for coverage determination or organization determination, or to your appeal. Buckeye will respond to your grievance orally or in writing as fast as your situation requires, but no later than:

  • 2 business days for complaints related to accessing care or prescription drugs
  • 30 calendar days for all other complaints

Filing a grievance

You or your appointed representative can file a grievance by:

Calling: 
Buckeye Member Services at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m., Monday through Friday. TTY users call 711.

Writing:
Buckeye Health Plan-My Care Ohio
Appeals and Grievance-Medicare Operations
7700 Forsyth Blvd
Saint Louis, MO 63105

As a courtesy, you can utilize the plan form located below or in Chapter 9 of your Member Handbook to file your complaint/grievance.

For process or status questions, you can contact us at 1-866-549-8289 (TTY users call 711). Your provider can contact us at 1-866-296-8731 for questions related to grievances and appeals.

For help with complaints, grievances, and information requests, you can also contact CMS by calling 1-800-MEDICARE (1-800-633-4227) or TTY 1-877-486-2048. Calls to this number are free, 24 hours a day, 7 days a week or going online to https://www.medicare.gov/MedicareComplaintForm/home.aspx.

 

Last Updated: 09/30/2017
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