SERVICE DETERMINATION REQUEST AND APPEALS PROCESS
WHAT IS A SERVICE DETERMINATION REQUEST?
You or your representative/caregiver (an individual authorized under State or other applicable law to act on behalf of a beneficiary and who is actively involved in the participant’s plan of care.) may request to initiate, modify, or continue a particular service. This request may be submitted either in writing or by speaking to any Element Care staff member. Element Care is obligated to provide an initial response to service determination requests within 3 days of receipt by the Interdisciplinary Team (IDT) as set forth in Element Care’s policy and in state and federal regulation. An extension, up to five days, can be filed by the IDT in addition to the initial response time. Notice of the extension and reason will be communicated verbally and in writing within 24 hours of the extension being filed.
WHAT IS AN APPEAL?
An appeal is an action taken due to Element Care’s non-coverage of, or nonpayment for, a service. This may include the starting, modifying, or continuation of certain services. In accordance with PACE regulations, if you or your representative/caregiver wishes to appeal a service determination request denial for reconsideration, you must furnish this request within 30 days of receiving the denial decision, either verbally or in writing. Element Care will automatically proceed with a Standard Appeal, which will be resolved as expeditiously as your health requires but no later than 30 calendar days. If you feel that the service you are appealing may endanger your life, health, or the ability to regain or maintain maximum health function, you have the right to an Expedited Appeal within 72 hours. If you or your representative/caregiver choose to appeal, all your services continue during the process regardless if you have Medicare and/or Medicaid, and your privacy will be protected.
WHO IS INVOLVED?
All Element Care participants or their designated representatives have the right to appeal a denied service request within 30 days of receiving the denial decision.
HOW DOES IT WORK?
You and, if applicable, your representative/caregiver will be invited to attend an internal appeal hearing to explain your case. An internal appeal hearing is a formal meeting that would be comprised of you, your representative/caregiver (if applicable), your IDT, and an Internal Review Board (IRB). The IRB consists of appropriately credentialed and impartial subject matter experts not originally involved in the service determination request decision and who do not have a stake in the outcome of the appeal. You are able to share any documentation you have as to why this service should be upheld. You may also contact the Element Care’s Participant Services department at 781-715-6612, and a representative will be able to assist you with preparations. Members from your IDT will also present information on the decision to deny the service in dispute. Each side will be heard, and the IRB will be responsible for deciding the outcome. You will be notified of the outcome in writing no later than 30 days after receipt of the appeal.
WHAT IF I AM UNSATISFIED WITH THE OUTCOME?
If the decision to deny is upheld at the appeals hearing, you have the right to appeal externally with Medicare or Medicaid, depending on your eligibility:
- Medicare beneficiaries may pursue an external appeal through the Independent Review Entity that contracts with CMS.
- Medicaid beneficiaries may pursue an external appeal through the State Fair Hearing Process.
In the event that you are dually eligible, it is up to you or your representative/caregiver to decide which external method to pursue. If you are only eligible for either Medicare or Medicaid, you must pursue the applicable external review. An Element Care staff member is able assist you and, if applicable, your representative/caregiver with this process if needed. External appeals may be sent in writing to:
MassHealth
Board of Hearings
100 Hancock Street, 6th Floor
Quincy, MA 02171
Phone: 800-655-0338
Medicare
Maximus Federal Services Inc.
Medicare Managed Care & PACE Reconsideration Project
3750 Monroe Avenue, Suite 702
Pittsford, NY 14534-1302
Phone: 585-348-3300
1/24/2024 PACE-PRT-400.A1 Service Determination Request and Appeals Process
GRIEVANCE PROCESS
A grievance is a complaint, concern, issue, or problem, presented in writing or verbally that expresses dissatisfaction. A grievance may include but is not limited to service delivery, quality of care, and violation of participant rights. You have the right to file a grievance about anything that concerns your care. All Information gathered during the investigation will be kept confidential and Element Care will continue to furnish you all of the required services included in your plan of care.
All of us at Element Care share responsibility for your care and your satisfaction with the services you receive. Our grievance process is designed to enable you, a family member/caregiver actively involved in your plan of care, or representative to express any concerns, grievances, or dissatisfaction you may have so they can be addressed. This will help us find areas for improvement, no matter how small. At any time, should you wish to file a grievance, we are available to assist you with the process. Element Care will provide communication services and/or devices, including but not limited to translations, interpreters, large print materials and audio format, as applicable, to assist with the grievance process as well as during typical daily services and needs.
The following steps outline the Grievance Process:
1. Discuss your grievance with any Element Care staff member. This person will make sure your grievance is documented. You are also welcome to register a written grievance.
Mail to: Element Care
Participant Services
235 Woodland North
Lynn, MA 01904
phone #: 781-715-6612
email to: customerservice@elementcare.org
fax to: 781.780.7856
2. You have the right to register a grievance with the Centers for Medicare & Medicaid Services (CMS) and if you have Medicare, you have the right to file a complaint with the quality improvement organization (QIO). Element Care will cooperate with both organizations to resolve the complaint.
3. The staff member who receives the grievance will help you document your grievance and coordinate investigation and action with the Center Manager or designee. We will investigate, work to find a solution, and take appropriate action(s) to resolve your grievance.
4. The staff member will address your grievance in a timely manner, but it may take up to 30 calendar days from the time your grievance was originally received. If you submitted a grievance with the Centers for Medicare & Medicaid Services (CMS) and your complaint is categorized as an immediate need complaint a resolution will be provided within two calendar days from the assignment date; if it was categorized as an urgent complaint a resolution will be provided within seven calendar days from the assignment date. The assignment date is the date CMS assigns a complaint to Element Care.
5. Once the grievance has been resolved, the Center Manager or designee will provide you with a resolution letter as well as notify you of the resolution within 3 calendar days.
6. If you, your family member/caregiver or representative are still not satisfied with the resolution as provided within Element Care’s internal grievance process, the Center Manager will advise you that you can file a grievance with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically throughout the office for Civil Rights Portal, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
If you have Medicare and are not satisfied with the resolution you also have the option of contacting 1-800-MEDICARE (1-800-633-4227).