We will send you a written decision explaining why we denied your request. If an Initial Determination does not provide you all that you requested, you have the right to appeal the decision.
You may ask us to review our Initial Determination, even if only part of our decision is not what you requested. An appeal to the Plan about Part C medical care or services is also called a Plan "Reconsideration". When we receive your request to review the Initial Determination, the request is evaluated by a person who was not involved in making the Initial Determination.
If you are appealing an Initial Determination, you, your Authorized Representative or your Doctor may file a standard appeal request or an expedite appeal request.
You or somebody that you have designated may ask us for a reconsideration. The person that you designate will be your “Authorized Representative.” You may designate a family member, a friend, an intercessor, a physician, or any other person to act on your behalf. Other persons may already be authorized to act on your behalf under State Laws. If you would like for someone who is not yet authorized under the State Laws to act on your behalf, then both, you and said person must sign and date an Appointment of Representative, which will grant that person the Legal authority to be your Authorized Representative. You are also entitled to have an Attorney act on your behalf.
However, Providers who do not have a contract with the Plan may also appeal a payment decision as long as the provider signs a “Waiver of Liability”(WOL) statement, which provide, that the Non-Contract Provider will not bill you, regardless of the outcome of the Appeal.
A request for Reconsideration must be filed within sixty (60) calendar days from the date of the notice of the adverse Initial Organization Determination. When good cause is shown, MCS may accept written request for Reconsideration after sixty (60) calendar days.
Appeals request - about your Medical Care and Services
To request a standard appeal regarding Part C medical care or services, you, your Physician, or your Authorized Representative may visit any of MCS Service Centers or may call our MCS Classicare Customer Service Call Center at 1-866-627-8183 (Toll free) or TTY 1-866-627-8182 (number for hearing impaired people). Our service hours are Monday through Sunday from 8:00 a.m. to 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m. You may also send your request by fax at 787-620-7765, or by mail at the following address: MCS Advantage, Grievances & Appeals Unit, P.O. Box 195429, San Juan, P.R. 00919-5429.
If you are appealing a determination that we have made about providing you with a Part C medical care or service that you have not yet received, you and/or your Physician must evaluate whether you need an expedite appeal.
To request an expedite appeal from us, you can visit any of MCS Service Centers or call 1-866-627-8183 (Toll free) or at TTY 1-866-627-8182 (number for the hearing-impaired people). Our service hours are Monday through Sunday from 8:00 a.m. to 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m. You may also send your request by fax at 787-620-7765, or by mail at the following address: MCS Advantage, Grievances & Appeals Unit, P.O. Box 195429, San Juan P.R. 00919-5429.
Make sure to request an “expedite” appeal. If your doctor requests an expedite appeal for you, or supports you in asking for one, and the Doctor indicates that waiting for a standard appeal could seriously harm your health or your ability to function, we will automatically expedite your appeal.
If you request an expedite appeal without the support from a Doctor, we will decide if you require an expedite appeal. If we decide that your medical condition does not meet the requirements for an expedite review, we will send you a letter informing you that if you get a Doctor’s support for an expedite review, we will automatically expedite your appeal. The letter will also provide you orientation in how to file an “expedite grievance.” You have the right to file an expedite grievance if you disagree with our decision to deny your request for an expedite review. If we deny your request for an expedite appeal, we will give manage your request as a standard appeal.
We must gather all the information we need to make a decision about your Appeal. If we need your assistance in gathering this information, we will contact you or your Authorized Representative. You have the right to obtain and include additional information as part of your Appeal. For example, you may already have documents related to your request, or you may want to get your Doctor’s records or opinion to help support your request. You may need to give the Doctor a written request to get information.
MCS provides you a reasonable opportunity to present, in person and in writing, evidence and testimony and make legal and factual arguments regarding your appeal, considering the limited time available to present evidence sufficiently in advance of the resolution timeframe for expedite and standard appeals.
You also have the right to ask us for a copy of information regarding your Appeal.
After we receive your appeal request, we have 60 days to decide. If we do not decide within 60 days, your appeal automatically goes to Level 2 appeal.
For Dual eligible enrollees (Medicare and Medicaid) we have 30 days to determine an standard appeal, and 72 hours to determine an expedite appeal, and if you ask for more time, or if we understand that helpful information is missing, we can require up to 14 additional calendar days to make our decision. If we do not decide within 30 days for a standard appeal or 72 hours for an expedite appeal (or by the end of the extended 14 calendar days), your request will automatically go to Level 2 Appeal.
After we receive your Appeal, we have 30 days to decide, but will decide sooner if your health condition requires. However, if we understand that helpful information is missing and may benefit you, or if you need more time to prepare for this revision, we may require up to 14 additional days to make the decision. If we do not inform you our decision within 30 days (or by the end of the extended time period), your request will automatically go to Appeal Level 2.
After we receive your request, we have 72 hours to decide, but will decide sooner if requires by your health condition. However, if you request more time, or if we understand that helpful information is missing and may benefit you, we can require up to 14 additional days to make our decision. If we do not decide within 72 hours (or by the end of the extended time period), your request will automatically go to Level 2 Appeal.
After we receive your appeal, we have 72 hours to decide, but will decide sooner if required by your health condition. Part B drugs appeals cannot be extended.
After we receive your appeal, we have seven (7) calendar days to decide. Part B drugs appeals cannot be extended.
We must pay within 60 days of receiving your Appeal request.
For dual eligible enrollee's (Medicare and Medicaid) we must pay within 30 days of receiving your appeal request (or by the end of the additional 14 calendar days of the extended period). For an expedite appeal we have to authorize payment within the 72 hours of receiving your appeal request (or by the end of the additional 14 calendar days of the extended period).
We must authorize or provide your requested care within 30 days of receiving your Appeal request. If we extended the time needed to decide your Appeal, we will authorize or provide your requested care before the extended time period expires.
We must authorize or provide your requested care within 72 hours of receiving your Appeal request. If we extended the time needed to decide your Appeal, we will authorize or provide your requested care before the extended time period expires.
We must authorize or provide your requested drug within 72 hours of receiving your appeal request. This 72-hour adjudication timeframe for appeals related to Part B drugs cannot be extended.
We must authorize or provide your requested drug within seven (7) days of receiving your appeal request. This 7-day period adjudication timeframe for appeals related to Part B drugs cannot be extended.
At the second level of Appeal, your Appeal is reviewed by an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS), the Government Agency that regulate the Medicare program. The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this Entity.
If you asked for Part C Medical care or services, or payment for Part C Medical care or services, and we did not rule completely in your favor at Level 1 Appeal, your appeal is automatically sent to the IRE.
If both your Level 1 and Level 2 appeals are denied, and/or if the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal.
There are three additional levels of appeal after Level 2, for a total of five levels of appeal:
The written responses you receive with the decisions to your appeals will explain how to continue with a next Level appeal and the applicable rules. Please see Chapter 9, or Chapter 7 for MCS Classicare Patriot (HMO), in your Evidence of Coverage for additional information.
When you are admitted in a Hospital, you have the right to get all the Hospital care covered by the Plan that is necessary to diagnose and treat your illness or injury. The day you leave the Hospital (your discharge date) is based on when your stay in the Hospital is no longer medically necessary. This section explains what to do if you believe that you are being discharged too soon.
Within two (2) days of admission as an inpatient or during pre-admission, someone at the Hospital must give you a notice called the Important Message from Medicare. To obtain a sample Notice you can contact MCS Classicare Customer Service Call Center at 1-866-627-8183 (Toll free) or at TTY 1-866-627-8182 (number for hearing impaired people). Our service hours are Monday through Sunday from 8:00 a.m. to 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8.00 a.m. to 8.00 p.m. and Saturday from 8.00 a.m. to 4.30 p.m.; or call 1-800-MEDICARE (1-800-633-4227), TTY users should call 1-877-486-2048, 24 hours a day/7 days a week or access online at https://www.cms.gov/BNI). This notice explains:
You (or your Authorized Representative) will be asked to sign the Important Message Notice from Medicare to show that you received and understood this notice. Signing the notice does not mean that you agree that the coverage for your services should end – only that you received and understand the notice. If the Hospital gives you the Important Message Notice from Medicare more than 2 days before your discharge day, it must give you a copy of your signed Important Message Notice from Medicare before you are scheduled to be discharged.
You have the right to request a review of your discharge. You may ask a BFCC-QIO to review whether you are being discharged too soon.
BFCC-QIO stands for Beneficiary Family Centered Care Quality Improvement Organization. The BFCC-QIO is a group of Doctors and other health care experts paid by the Federal Government to check on and help improve the care given to Medicare patients. They are not part of the Plan or the Hospital. There is one BFCC-QIO in each State. In Puerto Rico, the appointed entity is called Livanta. The Doctors and other health experts in Livanta, review certain types of grievances and appeals made by Medicare patients. These include appeals from Medicare patients who think their Hospital stay is ending too soon.
You must contact Livanta.
Livanta LLCBFCC-QIO10820 Guilford Road, Suite 202Annapolis Junction, MD 20701-1105Local telephone number: 787-520-5743Toll free Number: 1-866-815-5440TTY (for hearing impaired people): 1-866-868-2289 Fax: (855) 236-2423 Service hours: Monday through Friday 9:00 a.m. a 5:00 p.m. Saturday and Sunday 11:00 a.m. a 3:00 p.m.24 hours voicemail service is available https://livantaqio.com/en
The Important Message from Medicare also gives the name and telephone number of Livanta and tells you what you must do.
We will continue to cover your Hospital stay (except for any applicable co-payments or deductibles) for as long as it is medically necessary, and you have not exceeded our Plan coverage limitations.
You will not be responsible for paying the Hospital charges until noon of the day after Livanta gives you its decision. However, you could be financially liable for any inpatient hospital services provided after noon of the day after Livanta gives you its decision. You may leave the Hospital on or before that time and avoid any possible financial liability.
If you are still in the Hospital and dissatisfied with the determination, you may request a reconsideration to the IRE. However, you could be financially liable for any inpatient hospital services provided after noon of the day after Livanta gave you its first decision.
If you are no longer an inpatient in the Hospital and are dissatisfied with the determination, you have the right to pursue the standard appeal process with ALJ, MAC or at a Federal Court.
IRE has 14 days to decide whether to uphold its original decision or agree that you should continue to receive inpatient care. If they agree that your care should continue, we must pay for or reimburse you for any care you have received since the discharge date on the Important Message from Medicare, and provide you with inpatient care (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations.
If IRE upholds Livanta original decision, you may be able to Appeal its decision to an Administrative Law Judge (ALJ). Please see Appeal Level 3 of this section for guidance on the ALJ appeal. If the ALJ upholds the decision, you may also be able to ask for a review by the Medicare Appeals Council (MAC) or a Federal court. If any of these decision makers agree that your stay should continue, we must pay for or reimburse you for any care you have received since the discharge date, and provide you with inpatient care (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations.
If you do not ask Livanta for an expedite review of your discharge, no later than midnight from the day you are scheduled to be discharge from the Hospital, you may ask us for a “expedite appeal”. If you ask us for an expedite appeal of your discharge and you stay in the Hospital past your discharge date, you may have to pay for the hospital care you receive past your discharge date. Whether you have to pay or not depends on the decision we make.
If we uphold our original decision, we will forward our decision and case file to the Independent Review Entity (IRE) within 24 hours. Please see Appeal Level 2 of this section for guidance on the IRE appeal. If the IRE upholds our decision, you may also be able to ask for a review by an ALJ, MAC, or a Federal court. If any of these decision makers agree that your stay should continue, we must pay for or reimburse you for any care you have received since the discharge date on the notice you got from your provider, and provide you with any services you asked for (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations.
When you are a patient in a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF), you have the right to get all the SNF, HHA or CORF care covered by the Plan that is necessary to diagnose and treat your illness or injury. The day we end coverage for your SNF, HHA or CORF services is based on when these services are no longer medically necessary. This section explains what to do if you believe that coverage for your services is ending too soon.
Your Provider will give you written notice called the Notice of Medicare Non-Coverage at least 2 days before coverage for your services ends. To receive a sample Notice yon can contact MCS Classicare Customer Service Call Center at 1-866-627-8183 (Toll free) or TTY/TTD 1-866-627-8182 (for hearing impaired people). Our service hours are Monday through Sunday from 8:00 a.m. to 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m.; or call 1-800-MEDICARE (1-800-633-4227), TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; or access it online at https://www.cms.gov/BNI. You (or your Authorized Representative) will be asked to sign and date this Notice to show that you received it. Signing the notice does not mean that you agree that coverage for your services should end – only that you received and understood the Notice.
You have the right to Appeal our decision to end coverage for your services. As explained in the Notice you received from your Provider, you may ask Livanta, LLC (“Livanta”) to complete an independent review of whether it is medically appropriate to end coverage for your services.
Livanta will ask why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish. Livanta will also look at your medical information, talk to your Doctor, and review information that we have given to them. During this process, you will get a notice called the Detailed Explanation of Non-Coverage giving the reasons why we believe coverage for your services should end. To receive a sample Notice you can contact MCS Classicare Customer Service Call Center at 1-866-627-8183 (Toll free) or 1-866-627-8182 TTY (hearing impaired number). Our service hours are Monday through Sunday from 8:00 a.m. to 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m.; or call 1-800-MEDICARE (1-800-633-4227), TTY users should call 1-877-486-2048, 24 hours a day/7 days a week, or access it online at https://www.cms.gov/BNI.
Livanta will make a decision after it receives all the information it needs.
We will continue to cover your SNF, HHA or CORF services (except for any applicable co-payments or deductibles) for as long as it is medically necessary, and you have not exceeded our Plan coverage limitations.
You will not be responsible for paying for any SNF, HHA, or CORF services provided before the termination date on the notice you get from your Provider. You may stop getting services on or before the date given on the Notice and avoid any possible financial liability. If you continue receiving services, you may still ask IRE to review its first decision if you make the request within 60 days of receiving Livanta’s first denial of your request.
IRE has 14 days to decide whether to uphold its original decision or agree that you should continue to receive services. If they agree that your services should continue, we must pay for or reimburse you for any care you have received since the termination date on the Notice you got from your Provider, and provide you with any services you asked for (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations.
If IRE upholds Livanta original decision, you may be able to appeal its decision to an Administrative Law Judge (ALJ). Please see Appeal Level 3 of this section for guidance on the ALJ appeal. If the ALJ upholds our decision, you may also be able to ask for a review by the Medicare Appeals Council (MAC) or a Federal Court. If either the MAC or Federal Court agrees that your stay should continue, we must pay for or reimburse you for any care you have received since the termination date on the notice you got from your Provider, and provide you with any services you asked for (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations.
If you do not ask Livanta for a review by the deadline, you may ask us for an expedite appeal. If you ask us for an expedite appeal of your coverage ending and you continue getting services from the SNF, HHA, or CORF, you may have to pay for the care you get after your termination date. Whether you have to pay or not depends on the decision we make.
If we uphold our original decision, we will forward our decision and case file to the Independent Review Entity (IRE) within 24 hours. Please see Appeal Level 2 of this section for guidance on the IRE appeal. If the IRE upholds our decision, you may also be able to ask for a review by an ALJ, MAC, or a Federal court. If any of these decision makers agree that your stay should continue, we must pay for or reimburse you for any care you have received since the discharge date on the Notice you got from your Provider, and provide you with any services you asked for (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations.
As a Member of MCS, you have the right to access information such as the number of Quality of Care Grievances and Appeals made by Members; the Plan’s performance ratings, including how it has been rated by Plan Members, and how it compares to other Medicare Advantage health plans.
If you are interested in any of this information, please call MCS Classicare Customer Service Call Center at 787-620-2530 (Metro area), 1-866-627-8183 (Toll free number) or TTY 1-866-627-8182 (for hearing impaired people). Our service hours are Monday through Sunday from 8:00 a.m. to 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m. Also, you can request it by fax at 787-620-7765 or by mailing to the following address: MCS Advantage, Inc., Grievances and Appeals Unit, P.O. Box195429, San Juan P.R. 00919-5429.