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 calendar days after we hear your appeal (7 days for appeals related to medications). However, if you or your provider ask for more time or if we need to gather more information, we may take up to 14 more calendar days. If we take the extra days to make a decision, we will send you a letter that explains why we need more time. We can’t take the extra days for a Part B or Part D prescription drug appeal.
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 60 calendar days.
Fast Appeal - You will get an answer within 72 hours after we get your appeal. However, if you or your provider asks for more time, or if we need to gather more information, we may take up to 14 more calendar days. If we take extra days to make the decision, we will send a letter that explains why we need to take more time. We can’t take extra time to make a decision if your appeal is for a Medicare Part B or Part D prescription drug.
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 must be requested within 60 calendar days of the decision you are appealing and the 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. The timeframe to submit additional information for an expedited appeal is limited due to the short timeframe to process your appeal:
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:
Write, mail, FAX, deliver your appeal or call us.
Part C (and Part B Drugs) Appeals:
Buckeye Health Plan - MyCare Ohio
Appeals & Grievances
Medicare Operations
7700 Forsyth Blvd
St. Louis, MO 63105
Phone: 1-866-549-8289 (TTY: 711)
FAX: 1-844-273-2671
Part D Appeals:
Buckeye Health Plan - MyCare Ohio
Medicare Part D Appeals
P.O. Box 31383
Tampa, FL 33631-3383
Phone: 1-866-549-8289 (TTY: 711)
Fax: 1-866-388-1766
If you ask for an appeal and we continue to deny your request for a service or payment of a Medicare-covered service, we will send you a written decision and forward your case to the Medicare Independent Review Entity (IRE). If the IRE denies your request, the written decision will explain if you have additional appeal rights.
If you ask for an appeal and we choose to deny your request for a Medicaid service or payment of a service, we’ll send you a written appeal denial notice. This notice is called the Notice of Appeal Decision. It will explain the Level 2 External Appeal process for Medicaid services. This process involves a review by an independent organization that is not connected to the plan. You must exhaust the plan’s Level 1 Internal Appeals process prior to filing for review through the Ohio Department of Medicaid, Bureau of State Hearings.
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 Appeal Decision about a drug or medical service, the letter will include information about how you can file for 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 Services at 1-866-549-8289 (TTY: 711). 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.
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
Attn: Provider Appeals
P. O. Box 3060
Farmington, MO 63640
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
- 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, TTY users call 711. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day.
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.