Refer to Chapter 9 of your EOC for more information

What to do if you have a problem or concern: Your health and satisfaction are important to us. When you have a problem or concern, we hope you’ll try an informal approach first by calling Touchstone Health Member Services. We will work with you to try to find a satisfactory solution to your problem. You have rights as a Member of our plan and as someone who is getting Medicare. We pledge to honor your rights, to take your problems and concerns seriously, and to treat you with respect.

Two formal processes for dealing with problems: Sometimes you might need a formal process for dealing with a problem you are having as a member of our plan. There are two types of formal processes for handling problems:

• For some types of problems, you need to use the process for coverage decisions and making appeals.
• For other types of problems you need to use the process for making complaints.

Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you.

What is a grievance/complaint?: A grievance is a complaint you make regarding quality of care or service received by any Touchstone Representative, network doctor, hospital, facility or pharmacy – including staff. A grievance does not involve complaints about coverage. Examples of a grievance would be (but are not limited to):

• Service problems from Member Services.
• Waiting too long for prescriptions to be filled.
• Rude behavior by a network pharmacist, provider or anyone representative of Touchstone Health.
• Problems with the quality of medical care or services or cleanliness or condition of doctor’s offices, clinics or hospitals.

A complaint must be made within 60 days of the incident. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. In some cases, we may extend the timeframe by up to 14 days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

What is a coverage decision?: A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We make a coverage decision for you whenever you go to a doctor for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay:

• Usually, there is no problem. We decide the service or drug is covered and pay our share of the cost.
• But in some cases we might decide the service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

What is an appeal?: An appeal is a formal way of asking us to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision we have made to check to see if we were being fair and following all of the rules properly. When we have completed the review we give you our decision. You can appeal the following examples of Coverage Decisions:

For medical care coverage decisions:

• You are not getting certain medical care you want, and you believe that this care is covered by our plan.
• Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan.
• You have received medical care or services that you believe should be covered by the plan, but we have said we will not pay for this care.
• You have received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care.
• You are being told that coverage for certain medical care you have been getting will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.

For Part D prescription drug coverage decisions:

• You ask us to make an exception, including:
• Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs
• Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get)
• Asking to pay a lower cost-sharing amount for a covered non-preferred drug
• You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan’s List of Covered Drugs but we require you to get approval from us before we will cover it for you.)
• You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.

What is an exception?: If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are examples of exceptions that you or your doctor or other prescriber can ask us to make:

• 1. Covering a Part D drug for you that is not on our plan’s List of Covered Drugs (Formulary). (We call it the “Drug List” for short.)
• 2. Removing a restriction on the plan’s coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on the plan’s List of Covered Drugs.

The extra rules and restrictions on coverage for certain drugs include:

• 1. Being required to use the generic version of a drug instead of the brand-name drug.
• 2. Getting plan approval in advance before we will agree to cover the drug for you. (This is sometimes called “prior authorization.”)
• 3. Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called “step therapy.”)]
• 4. Quantity limits. For some drugs, there are restrictions on the amount of the drug you can have.

If our plan agrees to make an exception and waive a restriction for you, you cannot ask for an exception to the copayment or co-insurance amount we require you to pay for the drug.

The time required to make a decision on your appeal will depend on they type of appeal made.

Part C

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:

• You can call us at Member Services (1-888-777-0204, TTY 1-877-867-5814 Monday to Friday, 8AM-8PM).
• To get free help from an independent organization that is not connected with our plan, contact your State Health Insurance Assistance Program
• Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision or a Level 1 Appeal on your behalf. To request any appeal after Level 1, your doctor or other provider must be appointed as your representative.
• You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.

Medicare Advantage (Part C) Medical Appeals:

• For a decision about payment for medical care you already received – After we receive your appeal, we have 60 calendar days to make a decision.
• For a standard decision about medical care you have not yet received. -- After we receive your appeal, we must give you our answer within 30 calendar days, but will make it sooner if your health condition requires. However, if you request an extension, or if we find that some information is missing which can benefit you, we can take up to 14 more calendar days to make our decision.
• If your health requires it, ask us to give you a “fast decision”. This means we will answer within 72 hours. As explained above, we can take up to 14 more days under certain circumstances. The requirements and procedures for getting a “fast appeal” are the same as those for getting a “fast decision”

Making a Complaint (Part C)

Contact Touchstone Health – either by phone or in writing.

• Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. 1-888-777-0204, TTY 1-877-867-5814, Monday to Friday, 8AM-8PM.
• If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, put your complaint in writing, we will respond to your complaint in writing.
  
  If you do this, it means that we will use our formal procedure for answering grievances.

Here’s how it works:

• When a Member submits a written grievance, it is date stamped and forwarded to the Appeals and Grievance Unit.
• A letter is sent to the member acknowledging receipt of the grievance and if needed requesting additional information.
• Cases are automatically expedited and a decision rendered and communicated to the member and provider within 24 hours when:
  
  • A provider requests it because a delay would seriously jeopardize the Member’s life or health or ability to attain, maintain or regain maximum function.
  • Touchstone has extended the time frame for a service authorization or an appeal
  • Touchstone has refused a Member’s request for an expedited service authorization or an appeal.

A decision is made as quickly as the Member’s health status warrants but the resolution notice is mailed in no later than 30 calendar days from the date the grievance was received by Touchstone Health.

Part D

How To Ask For a Part D Prescription Drug Coverage Decision, Including an Exception: You can ask our plan to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a “fast decision.” You cannot ask for a fast decision if you are asking us to pay you back for a drug you already bought. You should request the type of coverage decision you want. You or your doctor or someone else who is acting on your behalf can ask for a coverage decision.

For a decision about payment for Part D prescription drugs you already received -- After we receive your appeal, we have 7 calendar days to make a decision. If we find in your favor, we have 30 days from the date of receipt of your request to issue payment.

If your health requires it, ask us to give you a “fast decision”
When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 72 hours after we receive your doctor’s statement. A fast decision means we will answer within 24 hours.

• To get a fast decision, you must meet two requirements:
  • You can get a fast decision only if you are asking for a drug you have not yet received. (You cannot get a fast decision if you are asking us to pay you back for a drug you are already bought.)
  • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
• If your doctor or other prescriber tells us that your health requires a “fast decision,” we will automatically agree to give you a fast decision.

Independent Review of Denied Appeal
If we deny any part of your Medicare Advantage (Part C) Medical Appeal or Part D Prescription Drug Appeal, you must request in writing for your case to be independently reviewed by an independent review organization. This independent review organization contracts with the Federal government. The independent review organization will review our decision. If any of the medical care or service you requested is still denied, you can appeal to an administrative law judge (ALJ) if the dollar value of your appeal meets the minimum Federal requirement. You will be notified of your appeal rights if this happens.

To request coverage decisions and appeals, please refer to the contact information below:

Coverage Decisions for Medical Care

Toll-Free: 1-888-777-0204
TTY: 1-877-867-5814
Hours: October 15, 2011 – December 7, 2011: 8AM to 8PM, 7 days a week; December 8, 2011 – October 14, 2012: 8AM to 8PM, Monday through Friday
Fax: 1-914-288-1215

Touchstone Health HMO, Inc.
PO Box 21994
Eagan, MN 55121

Appeals for Medical Care

Toll-Free: 1-888-777-0204
TTY: 1-877-867-5814
Hours: October 15, 2011 – December 7, 2011: 8AM to 8PM, 7 days a week; December 8, 2011 – October 14, 2012: 8AM to 8PM, Monday through Friday
Fax: 1-914-288-1215

Touchstone Health HMO Inc.
PO Box 21994
Eagan, MN 55121

Coverage Decisions for Part D Prescription Drugs

Toll-Free: 1-888-777-0204
TTY: 1-877-867-5814
Hours: October 15, 2011 – December 7, 2011: 8AM to 8PM, 7 days a week; December 8, 2011 – October 14, 2012: 8AM to 8PM, Monday through Friday
Fax: 1-866-632-7946

National Pharmaceutical Services
P.O. Box 407
Boys Town, NE 68010

Appeals for Part D Prescription Drugs

Toll-Free: 1-888-777-0204
TTY: 1-877-867-5814
Hours: October 15, 2011 – December 7, 2011: 8AM to 8PM, 7 days a week; December 8, 2011 – October 14, 2012: 8AM to 8PM, Monday through Friday
Fax: 1-866-632-7946

National Pharmaceutical Services
Medicare Part D Appeals,
P.O. Box 407
Boys Town, NE 68010

Members can send their grievance or complaint to the following address:
Touchstone Health HMO, Inc.
PO Box 21911
Eagan, MN 55121

Authorized Representative Form

Members and Enrollees may use the form below to obtain coverage determination:
Medicare Prescription Drug Coverage Determination Request Form

Providers may use the form below to obtain coverage determination:
Coverage Determination Form