Grievance and Appeals Rights

Beneficiaries of the UMWA Health and Retirement Funds have the right to file a grievance or complaint with the Funds.

Grievance is a complaint from a beneficiary about a specific event that is not related to payment or coverage of benefits and requires further action on part of the Funds. Grievance includes complaints about interpersonal aspect of care such as rudeness by a provider or failure to respect the rights of the beneficiary, dissatisfaction with physicians, facilities, providers, Funds’ staff or operations, or quality of care, as well as the timeliness, access, or appropriateness of a covered health care service or item. In addition, grievance includes complaints related to involuntary disenrollment of a beneficiary initiated by the Funds.

Appeal is a procedure for reconsidering the Funds decision to deny a health care service or payment that the beneficiary believes he or she is entitled to receive. This includes delay in providing, arranging for, or approving the health care services (such that a delay will jeopardize the health of the beneficiary) or any amounts that a beneficiary must pay for a service.

How to File a Grievance
The Funds has a grievance procedure to address complaints about quality of service or any other issue that is not about denial of a service or claim. You may submit an informal complaint to the Funds either by telephone or in writing. To discuss a concern you can call the Health Call Center at 1-800-291-1425.

Written complaints should be mailed to:

UMWA Health and Retirement Funds
PO Box 2320
Beckley, West Virginia 25802

All written grievances should include your name, address and a full explanation of your complaint, including specific dates, persons, places and events. In a clear statement, please tell us how you believe the problem should be resolved.

If you are Medicare-eligible beneficiary, you may also file a complaint about the quality of your care with your local Medicare Quality Improvement Organization.

Often complaints result from simple misunderstandings that can be resolved informally through discussions among the parties involved. The Health Call Center representative will log your call or letter and the nature of the issue and attempt to resolve the problem. If we cannot immediately resolve your concern, we will investigate it and respond to you by phone or letter within 30 days unless it is necessary to take an extension of up to14 calendar days to gather additional information/medical records and the extension of time benefits you. You will be notified in writing if the Funds needs additional time (up to 14 calendar days) to consider a grievance case.

We are committed to making every effort to informally resolve your grievance. If, however, the Funds’ representative cannot resolve your complaint or inquiry to your satisfaction, you or your authorized representative may file a second level grievance. This must be done in writing and sent to the address listed above. Funds’ staff will review your grievance for completeness and may ask for additional information. Once the grievance is complete, it will be referred to an Internal Grievance Committee for review. This committee is made up of one or more internal Funds’ management staff who has not previously been involved in your dispute.

The Internal Committee will review your complaint and make a decision within 30 days of the referral of your grievance, unless special circumstances (such as the need to schedule a meeting with you and/or other involved parties) require an extension. If an extension is necessary, you will be notified and will receive a decision in writing from the Committee no later than 90 days after the referral of your grievance. This decision will be final for the Funds.

Appeals

Should you be denied coverage for a health claim or service, you will be notified in writing and will be provided with information on the Funds’ appeal procedure. The following letter explains the Funds’ appeal process.

The Funds’ Health Call Center provides prompt responses to your questions and concerns. We encourage you to contact us whenever you have a question or concern about your plan or physician. We will work with you to get your questions answered and your issues resolved quickly.

Feel free to contact the Health Call Center toll-free at
1-800-291-1425 if you have any questions.
We’re here to help!

Dear Funds’ Medicare-Eligible Beneficiary:

The Centers for Medicare & Medicaid Services (CMS) has regulations governing your right to file a Medicare Appeal. As a Medicare-eligible beneficiary of a health plan administered by the UMWA Health and Retirement Funds, you have a right to a Medicare Appeal. Your appeal rights include a standard 30 calendar day appeal for a service, a standard 60 calendar day appeal for a payment and a 72 hour expedited appeal. This notice informs you of the current Medicare Appeal process. In addition, we provide you with useful information when filing a standard or expedited appeal.

You Have a Right To Appeal

You can appeal if you do not agree with the UMWA Health and Retirement Funds (hereafter the Funds) decision about your medical bills or health care. You have a right to appeal if you think:

• The Funds has not paid a bill
• The Funds has not paid a bill in full
• The Funds will not approve or give you care it should cover
• The Funds is stopping care you still need
  

The Funds normally has 30 calendar days to process your appeal for a service and 60 calendar days to process your appeal for a payment. In some cases, you have a right to a faster 72-hour appeal. You can get a fast appeal if your health or ability to function could be seriously harmed by waiting 30 calendar days for a standard appeal. If you ask for a fast appeal, the Funds will decide if you get a 72-hour fast appeal. If not, your appeal will be processed in 30 calendar days. If any doctor asks the Funds to give you a fast appeal, or supports your request for a fast appeal, the Funds must give it to you.

STANDARD APPEAL

There are two kinds of standard appeals:

1. Standard (30 calendar days) appeal for a service:
The Funds is responsible for processing your appeal request for service within 30 calendar days from the date the Funds receives your request or no later than the last day of the extension (up to 14 calendar days). Even though you may file your request with the Social Security Administration, that office will transfer your request to the Funds for processing.14-day extension

An extension up to 14 calendar days is permitted for a 30 calendar day appeal, if the extension of time benefits you; for example, if you need time to provide the Funds with additional information or if we need to have additional information. You will be notified in writing if the Funds needs additional time (up to 14 calendar days) to process your request. You have the right to file an expedited grievance if you disagree with the Funds decision to grant itself an extension.

2. Standard (60 calendar days) appeal for a payment:
The Funds is responsible for processing your appeal request for a payment within 60 calendar days from the date the Funds receives your request.

How to file a standard appeal?

1. File the request in writing, in person or by mail, or by telephone with the Funds or with an office of the Social Security Administration.
2. Written requests to the Funds should be mailed to :
United Mine Workers of America Health and Retirement
Funds, PO Box 64914, St. Paul, MN 55164 -0914
3. Written requests may be faxed to the Funds at: 1-800-382-7792
4. Telephone requests can be made by calling 1-800-292-2288
5. File your request within 60 calendar days of the date of the notice.

What happens next?

For a 30 calendar day appeal:
If the Funds does not rule in your favor, the Funds will forward your appeal request to the Centers for Medicare & Medicaid Independent Review Entity for a decision within 30 calendar days from the date the Funds received your request.

For a 60 calendar day appeal:
If the Funds does not rule in your favor, the Funds will forward your appeal request to the Centers for Medicare & Medicaid Services Independent Review Entity for a decision within 60 calendar days from the date the Funds received your request

EXPEDITED/72-HOUR APPEAL

Expedited appeal is processed within 72 hours and does not apply to denials of payment.

14-Day Extension
An extension up to 14 calendar days is permitted for a 72-hour appeal, if the Funds determines that an extension of time benefits you or if you request an extension; for example, if you need time to provide the Funds with additional information. You will be notified in writing if the Funds needs additional time (up to 14 calendar days) to process your request. You have the right to file an expedited grievance if you disagree with the Funds decision to grant itself an extension.

How to file an Expedited Appeal?

1) File an oral or written request for a 72-hour appeal. Specifically state that “I want an expedited appeal, fast appeal or a 72-hour appeal.” or “I believe that my health could be seriously harmed by waiting 30 calendar days for a normal appeal.”

2) To file a request orally, call 1-800-292-2288. The Funds will document the oral request in writing.

3) To hand deliver your request, our address is: United Mine Workers of America Health and Retirement Funds, PO Box 64914, St. Paul, MN 55164 - 0914

4) To FAX your request our FAX number is 1-800-382-7792. If you are in a hospital or a nursing facility, you may request assistance in having your written appeal transmitted to the Funds by use of a FAX machine.

5) To mail a written request, our address is: United Mine Workers of America Health and Retirement Funds, PO Box 64914, St. Paul, MN 55164 – 0914,

6) The 72-hour review time will not begin until your request for appeal is received.

7) You must file your request within 60 calendar days of the date of the notice.

What happens next?

If the Funds denies your request for an expedited appeal : the request will be processed within 30 calendar days or no later than the last day of the extension (up to 14 additional calendar days) from the date the Funds received your request for an expedited appeal. You have the right to file an expedited grievance with the Funds at 1800-291-1425 if the Funds denies your request for an expedited appeal.

If the Funds approves your request for an expedited appeal: the Funds will make a decision on your appeal and notify you of it within 72-hours of receipt of your request. If our decision is not fully in your favor, we will automatically forward your appeal request to the Centers for Medicare & Medicaid Services Independent Review Entity for an independent review within 24 hours of receipt of your request. Centers for Medicare & Medicaid Services Independent Review Entity will send you a letter with their decision within 72 hours of receipt of your case from the Funds.

“Support for Your Appeal, Who May File an Appeal, Help With Your Appeal, and Peer Review Organization Complaint Process”

The following information applies to Standard and Expedited Appeals

Support for Your Appeal

You are not required to submit additional information to support your request for services or payment for services already received. The Funds is responsible for gathering all necessary medical information, however, it may be helpful to you to include relevant medical records or physician opinions in support of your appeal. To obtain medical records, send a written request to your primary care physician. If your medical records from specialist physicians are not included in your medical record from your primary care physician, you may need to make a separate written request to the specialist physician(s) who provided medical services to you.

Who May File an Appeal?

1. You may file an appeal.
2. If you want someone to file the appeal for you:

a. Give us your name, your Medicare number, and a statement which appoints an individual as your representative. (Note: You may appoint your doctor.) For example “ I (your name) appoint (name of representative) to act as my representative in requesting an appeal from the Funds and/or the Centers for Medicare & Medicaid Services regarding the Funds’ (denial of services) or denial of payment for services).
b. You must sign and date the statement.
c. Your representative must also sign and date this statement unless he/she is an attorney.
d. Include this signed statement with your appeal.

3. A non-plan doctor may file a standard appeal of a denied claim if he/she completes a waiver of liability statement which says he/she will not bill you regardless of the outcome of the appeal.
4. A court appointed guardian or an agent under a health care proxy to the extent provided under state law.

Help With Your Appeal

If you decide to appeal and want help with your appeal, you may have your doctor, a friend, lawyer, or someone else help you. There are several groups that can help you. You may want to contact the Area Agency on Aging, the Insurance, Counseling and Assistance Program, the Medicare Rights Center at Toll Free 1-800-HMO-9050. Your Funds Health Call Center (1-800-291-1425) can also help you.