Important tips about the Appeals process for One Care
The Appeals process is a way to ask your One Care plan to reconsider a decision they have made about changing or denying your service or benefit.
When you ask your One Care plan for a service or benefit, they can either approve, change or deny your request.
Approve: Your One Care plan can say “Yes” (approve) the service or benefit exactly as you requested it.
Change: Your One Care plan may approve services or benefits with changes as to who, what, when, where, how or how often the service or benefit is provided.
If your plan approves your service or benefit request with changes and you do not agree with the changes, you can ask for an Appeal.
Deny: If your One Care plan says “No” to your request for a service or benefit it is called a denial or an “Adverse Action”. If your plan says “No”, you will receive a letter telling you why the plan denied your request and what steps you can take to appeal their decision – to ask other people to reconsider the service/benefit change or denial.
Anytime you get a “No” (a denial) or a change to your services or benefits that you do not agree with, you have the right to ask for an Appeal through 5 levels of Appeals. That means you have a right to ask someone else to reconsider the service or benefit change or denial.
IMPORTANT: EACH One Care service and EACH One care benefit may have a different Appeals process AND timelines. It is CRITICAL to review your One Care Member Handbook to find out exactly what process and timelines are required to ask for an Appeal depending on the specific service or benefit that was changed or denied.
Two kinds of Appeals You can ask for one of two kinds of an Appeal:
Asking for a “Standard Appeal”, means the people who make the decision must give you a written answer to your request within 30 days after they get your appeal. If the people who make the decision need more information, they may take up to 14 more calendar days before telling you their decision.
Fast Appeal (Also called an Expedited Appeal)
Asking for a “Fast Appeal”, means the people who make the decision must give you an answer within 72 hours after they get your appeal. If the people who make the decision need more information, they may take up to 14 more calendar days before telling you their decision.
NOTE: You can ask for a Fast Appeal ONLY if you or your health care provider believe your health, life or ability to regain maximum function may be put at risk by waiting up to 30 days for a decision.
Timelines are IMPORTANT!
In order to get an Appeal, you MUST ask for the Appeal within a time limit from the date on the letter which tells you about a denial or change to you service or benefit request.
Different types of Appeals have different time limits. Sometimes you have only 10 days (from the date on the notification letter) to ask for an Appeal. Sometimes you have 30 days or 60 days (from the date on the notification letter) to ask for an Appeal. Be sure to check the denial (Adverse Action) letter to know how much time you have to ask for an Appeal.
If you miss the deadline, you can ask for more time to ask for an Appeal.
My experience since joining One Care
Joining One Care, there are good decisions and there are great decisions. For me this was a great decision. I’ve been with them right from the start. After receiving information in the mail about changes in my health insurance I wanted to know more. Change is scary. What if I end up a side effect of this new plan? With lots of things going horribly wrong. Things prior to One Care weren’t that bad, but I knew or hoped even prayed it could be better.
Knowledge is power. I’ve heard it. I’ve said it. I didn’t want to sit with arms crossed saying, “okay One Care…show me what you’ve got.” (secretly I was saying exactly that) I was getting by. At least that’s what I thought. I was really that orphan from the play going to the health plans with my empty bowl. “Please sir can I have another?” You know the play or movie. I deserved better. I found it. I have a Care Coordinator. This person guides me to and through the plan. We started with a Needs Assessment. Wait, wait, wait! You want to know what I need? What’s the catch? There are no co-pays? Must be during the trial period? No, none…ever. I was looking for “Candid Camera” was I on “Punked”? Someone was pulling my leg. Health plans don’t just help you without making you sorry first. Welcome to One Care. In my head there was a choir of angels. The best thing I heard, if you don’t like us you can go back. Go back? To being on hold so long you forgot why you called. Less is not more, it’s just less. With a chronic illness worrying equals stress I just don’t need. One Care took away my worries about my health care and gave me the support and tool I need for a better life.
One Care plans help and listen. I attend their Consumer Action Council meetings. Quarterly we meet to discuss concerns and things that are going well with the plan. My voice matters.
A One Care Enrollee had been attempting to coordinate massage therapy services to treat their diagnosis of fibromyalgia and called the OCO for support. The OCO worked with the One Care plan Customer Service center and the Care Manager to locate a provider in network that was geographically accessible for the consumer. This consumer has since seen the massage therapist.
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