Grievance and Appeal Process Client Appeals

Transcription

1 Grievance and Appeal Process Client Appeals Appeals Of Adverse Benefit Determination - Client c2011

2 Page 2 Client Rights to File a Grievance and Appeal of an Adverse Determination of EAP Services and Benefits FEI Behavioral Health s (FEI) grievance resolution process is designed to address client concerns and to resolve problems. Grievances include both complaints and appeals. Complaints can include concerns about people, quality of service, quality of a providers service, benefit exclusions or eligibility. Appeals are requests to reverse a denial of service or modified decision about the services offered, not offered or the services that have been requested and not received. EAP Service benefits provided by FEI are services offered through an employee s employer. EAP Services include, but are not limited to, telephonic consultation, counseling, legal services, financial services and work-life services. As such, employees and their eligible dependents have the option of addressing their concerns directly to the employers designated plan sponsor or administrator. For Appeals of Adverse Determinations, FEI has established a Two Level Appeal process as a pathway for addressing a client concern. Service Complaint If you are concerned about the quality of service or care you have received, an EAP Services benefit exclusion, or have an eligibility issue, you may contact FEI to file a verbal or written complaint. If you call us to file a complaint on the phone, we will attempt to document and/or resolve your complaint at that time. If we receive your complaint in the mail, through the online Services Feedback Form, or via , FEI will attempt to contact you within 5 calendar days to resolve your concerns. Should you continue to be unsatisfied FEI will inform you how to file an Appeal of an Adverse Determination, what information is required and who to contact if you have questions. First Level Appeal If you believe that your request for EAP Services was wrongfully denied after contacting FEI to review the decision, you may file an appeal. Your appeal must be submitted in writing to FEI Behavioral Health, Inc. (FEI) within one hundred and eighty (180) days following the denial of the requested EAP Services.

3 Page 3 Your appeal should state the reasons why you feel your request for EAP Services is valid and include any additional documentation that you feel supports your request. You may also include any additional questions or comments. You may submit written comments, documents, records and other information relating to your appeal, whether or not the comments, documents, records or information were submitted in connection with the initial denial for EAP Services or Benefits. At your request, FEI will make relevant documents available to you. The review of the initial decision will consider all new information, whether or not it was presented or available for the initial decision. FEI s Chief Operating Officer or his designee will review and decide the appeal. The individual making this decision will be not be the same person who originally denied the request for EAP Services nor will that individual be a subordinate of the person making the original decision. When a decision is based on an EAP Professional s judgment, the reviewer will consult with an expert in the necessary field with appropriate training and experience and shall disclose the identity of any expert consulted and whether that expert was relied upon or not in making the final decision. You or your Authorized Representative will be notified of the appeal decision within the following time frames: a. If the case involves an Adverse Determination on a request for EAP Services, FEI will render a decision and communicate that to you within thirty (30) days of FEI s receipt of the request for appeal; b. If the Appeal you are seeking involves a post-service Adverse Determination where you incurred an out-of pocket expense, FEI will render a decision within thirty (30) days of FEI s receipt of the request for appeal. Appeal Decisions If you authorize written communication, FEI will give you or your Authorized Representative the decision on the appeal in writing. If the denial is upheld on the appeal, the notice will include: An explanation around the specific reason or reasons for the denial decision. Identification of Benefit Plan provisions and/or your employers benefit administration guide and instructions upon which the decision is based.

4 Page 4 The specific rule, guideline or protocol that was relied on in making the decision (if any) in the form of a copy of that document or a statement that it was used. A copy of referenced document will be made available to the client free of charge. An explanation of the basis for the EAP Professional judgment or a statement that further explanation will be made available, free of charge, to the client. A notice of your right to pursue a Second Level Appeal. Information on how to pursue a Second Level Appeal. A notice of your right to receive, upon request and without cost to you, reasonable access to, and copies of, all documents, records and other information relevant to making a Second-Level Appeal. If you do not authorize written notification, FEI will furnish this information to you or your Authorized Representative by telephone. Second Level Appeal If you disagree with the First Level Appeal determination, and wish to pursue further action you are entitled to file a Second Level Appeal request to review your case. Please review your benefit plan documents, Summary Plan Description (SPD), or contact your company s plan administrator to determine the appeals process available to you. If you do not agree with the final determination on review, you may have the right to bring a civil action under Section 502(a) of ERISA, if applicable. A copy of the specific rule, guideline or protocol relied upon in the adverse benefit determination will be provided free of charge upon request by you or your authorized representative. A Second-Level Appeal must be submitted in writing within 180 days following the date the First Level Appeal decision was communicated to you. Your appeal should state the reasons why you feel your request for EAP Services is valid and include any additional documentation that you feel supports your request. You may also include any additional questions or comments. You may submit written comments, documents, records and other information relating to your appeal, whether or not the comments, documents, records or information were submitted in connection with the initial denial for EAP Services or Benefits. At your request, FEI will make relevant documents available to you.

5 Page 5 How to File a Service Grievance or Appeal By Phone Call us toll-free at the number provided by your employer to access your EAP Services. Inform the EAP Counselor that you are seeking to file an Appeal and you will be provided the instructions on how to do so. By Mail or Send written grievances to: FEI Behavioral Health, Inc West Lake Park Drive Milwaukee, WI ATT: Chief Operating Officer Or by to: ganda@feinet.com For convenience purposes FEI will provide you with a Grievance and Appeal form, but you are not required to use the form to make a written Grievance or Appeal. Online You can download a Grievance and Appeal form or submit an online Service Feedback Form through your website: Click on the Service Feedback Form on the left of the screen under member Grievance and Appeals tab.

6 Page 6 FEI Behavioral Health EAP Services Grievance and Appeal Form Completion of this form is voluntary. To obtain a review, you or your authorized representative may also call FEI s EAP Services Center using the telephone number displayed on the members ID card or submit a request in writing to the address below. Today's Date: / / (MM/DD/YYYY) Employee Name: First Last Client Name: (If Different from Employee) First Last Relationship to the employee: Self Spouse Child Other Client's Date of Birth: / / (MM/DD/YYYY) Service Type: Counseling Services Financial Services Wellness Services Legal Services Work-life Services Other Services Service Date or Date of Initial Call to FEI: / / (MM/DD/YYYY) Explanation of Grievance/Appeal (Please use additional pages if necessary) You may mail or fax your request to: FEI Behavioral Health, Inc West Lake Park Drive Milwaukee WI Attention: Chief Operating Officer Fax number:

7 Page 7 FEI Behavioral Health, Inc. Provider Appeals Process FEI Behavioral Health, Inc. has designed a set of step-by-step instructions to question or appeal an EAP Services or claim payment decision. The process includes a reconsideration step as well as levels for an appeal. The procedures apply to individual practitioners as well as organizational providers such as hospitals and other facilities. The process applies to all FEI Behavioral Health, Inc. EAP Services products. The telephone number for FEI Behavioral Health, Inc. is The mailing address for correspondence related to appeals is West Lake Park Drive, Milwaukee, WI Reconsideration Reconsideration is the first step in questioning a claim payment decision. The provider must contact FEI Behavioral Health, Inc. s Network Operations Department within 180 days of the receipt of the initial claim determination. We advise the provider to have ready the relevant reference information available when contacting FEI Behavioral Health, Inc. FEI Behavioral Health, Inc. will provide a written or verbal response within five business days. If the decision is in the provider s favor, FEI Behavioral Health, Inc. will also recalculate and reprocess the claim for affected services. Depending upon the nature of the claim FEI Behavioral Health, Inc. may seek information or guidance from FEI s customer. A response will be completed within 30 business days unless additional information is requested. If the matter is not decided in the provider s favor, an Appeal may be initiated. Details on how to file the appeal will be provided when the reconsideration decision is given to the provider as follows. Appeals Process Appeals include a Billing Dispute Resolution Process and an EAP Services Benefit Review Process. FEI Behavioral Health, Inc. s Appeal Process for both types requires the provider to file an Appeal within 60 days of receipt of an adverse reconsideration decision. FEI Behavioral Health, Inc. has 30 business days after receipt of the Appeal to issue its decision to the provider. If the decision is in the provider s favor, FEI Behavioral Health, Inc. will also recalculate and reprocess the claim for affected services. As with the reconsideration of determinations, and depending upon the nature of the claim FEI Behavioral Health, Inc. may seek guidance from FEI s customer. A response will be completed within 30 business days unless additional information is requested.