WHA Care+

Appeals and Grievances

You have the right to make a complaint if you have concerns or problems related to your medical coverage or care. "Appeals" and "grievances" are different types of complaints you can make.

• An "appeal" is the type of complaint you make when you want us to reconsider and change a decision we have made about what services are covered for you or what we will pay for a service. For example, if we refuse to cover or pay for services you think we should cover, you can file an appeal. If WHA or one of our plan providers refuses to give you a service you think should be covered, you can file an appeal. If WHA or one of our plan providers reduces or cuts back on services you have been receiving, you can file an appeal. If you think we are stopping your coverage of a service too soon, you can file an appeal.



• A "grievance" is the type of complaint you make if you have any other type of problem with WHA Care+ or one of our plan providers. For example, you would file a grievance if you have a problem with things such as the quality of your care; problems with getting appointments when you need them or having to wait a long time for appointments; problems with how long you have to spend waiting on the phone, in the waiting room, at the pharmacy or in the exam room; rude behavior from your doctors, nurses, receptionists, pharmacists or others; being able to reach someone by phone or get the information you need; or the cleanliness or condition of the doctor's office.

For more detailed information on appeals and grievances, please see the 2008 WHA Care+ Evidence of Coverage. Appeals and grievances that involve your Medicare health benefits are discussed in Sections 8 and 9. Coverage determinations and appeals that involve your drug benefits are discussed in Section 10. Or you can contact our Member Services Department at 916-563-2250, 1-888-563-2250 toll free or 1-888-877-5378 TTY/TDD. Representatives are available from 8:00 a.m. to 5:00 p.m., Monday through Friday. An interactive voice response system is available at all other times. Appeals and grievances can be submitted in writing to: WHA Care+, Attn: Appeals Department, 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833, or faxed to 916-563-2207.

To obtain an aggregate number of WHA's grievances, appeals and exceptions, please contact our Member Services Department at 916-563-2250, 1-888-563-2250 toll free or 1-888-877-5378 TTY/TDD, Monday through Friday, 8:00 AM to 5:00 PM.

Coverage Determinations and Exceptions

You have the right to make a complaint if you have concerns or problems related to your Medicare prescription drug coverage. "Coverage determinations" and "exceptions" are different types of complaints you can make.

• A "coverage determination" is the first decision we make about covering the drug you are requesting. If your doctor or pharmacist tells you that a certain drug is not covered, you may call us for a coverage determination. This would include such things as authorizing prescription drugs, paying for prescription drugs or continuing to provide prescription drugs that you have been getting.
  
  
• An "exception" is a request to change our coverage rules for prescription drugs. For example, you can ask us to: cover your drug, even if it is not in our formulary; waive coverage restrictions or quantity limits of your drug; or provide a higher level of coverage for your drug (ask us to cover your Tier 3 Non-Preferred Brand drug as a Tier 2 Preferred Brand drug, which would lower the amount you pay for your drug).
  
  

Generally, WHA Care+ will only approve your request for an exception if the alternative drugs included on the plan's formulary, the low-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

For more detailed information on coverage determinations and exceptions, please see Section 10 of the 2008 WHA Care+ Evidence of Coverage. Or you can complete a copy of the attached Coverage Review Request Form and fax it to Medco at 1-800-711-5673. When you are requesting an exception in writing, you should submit a statement from your physician supporting your request. Generally, Medco must make their decision within 72 hours of the receipt of your request.

Appointment of Representative

Under the Medicare Part D prescription drug benefit program, a drug exception request can be made on behalf of the enrollee by the enrollee's appointed representative or the enrollee's prescribing physician.

To appoint an individual to act on your behalf as your representative regarding drug exception requests, please complete a copy of the attached Appointment of Representative form. This form must be signed by both you and your appointed representative.

Your completed form can be submitted to Medco along with your completed Coverage Review Request Form. Send the form(s) by fax to 1-800-711-5673.

Prior Authorization

Besides providing much of your care, your PCP will help arrange or coordinate the rest of the covered services you get as a plan member. This includes your x-rays, laboratory tests, therapies, care from doctors who are specialists, hospital admissions and follow-up care. "Coordinating" your services includes checking or consulting with other plan providers about your care and how it is going. If you need certain types of covered services or supplies, your PCP must give approval in advance (such as giving you a referral to see a specialist). In some cases, your PCP will need to get prior authorization (prior approval). Since your PCP will provide and coordinate your medical care, you should have all of your past medical records sent to your new PCP's office. Section 6 of the 2008 WHA Care+ Evidence of Coverage tells how we will protect the privacy of your medical records and personal health information.

In order to expand the choice of specialists, WHA has implemented a unique program called the Advantage Referral Program. This program allows access to all specialists in our network rather than just those who have a direct relationship with your Primary Care Physician. If he or she determines that your medical condition requires specialty care, you will be referred to any of the WHA Care+ network specialists. Self-referred annual well-woman exams, obstetrical services and mammograms are included in the Advantage Referral Program and do not require a PCP referral or prior authorization, as long as the provider is listed in the WHA Care+ Provider Directory.

In most cases, you will be comfortable with the specialist that your Primary Care Physician selects; however, if you already have a relationship with a network specialist, or prefer another network specialist, you may ask to be referred to him or her instead. The WHA Care+ Provider Directory lists all of the network specialists approved for referrals by your Primary Care Physician. Any provider not listed in the WHA Care+ Provider Directory is a non-participating provider, and you must obtain prior authorization from WHA before obtaining services. Please be sure to consult with your PCP if there are specific specialists or facilities that you want to use.

Prior authorization is also required for certain drugs. This means that you or your physician will need to get approval from Medco by calling 1-800-592-4526 before you fill your prescription. If you don't get approval, the drug may not be covered.

Step Therapy

In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

You can ask for an exception to these restrictions or limits by calling Medco at 1-800-592-4526.

back