Grievance Process and Appeals
All of us at Mercy LIFE of Alabama share the responsibility for assuring that you are satisfied with the care you receive. We understand that sometimes there are areas of dissatisfaction that require our attention and response. If you are dissatisfied, we encourage you to express any grievances. If you do not speak English, a staff member or volunteer who speaks your language will facilitate the grievance process.
A. Definition: A grievance is defined as a written or oral expression of dissatisfaction with service delivery or quality of care furnished.
When you have made your grievance known, Mercy LIFE of Alabama will discuss it with you and provide you with written information about the specific steps, including timeframes for response that will take place to resolve your grievance. You can discuss your concerns or send a letter to the Social Worker, Center Director or the Executive Director. Give complete information so that appropriate staff can help to resolve your concern in a timely manner.
B. The staff member who receives your grievance will help you document it (if it is not already in writing on the Grievance Form), and will forward it to the Mercy LIFE of Alabama Quality Assurance Coordinator to coordinate any further investigation and required action, as well as report the complaint at the appropriate Interdisciplinary Team meeting.
C. The Director of Operations and or Quality Assurance Coordinator will provide a written acknowledgment of the grievance and response as to the status of the grievance to you or your representative within ten (10) working days of Mercy LIFE of Alabama receiving the grievance.
D. If a solution is found by the staff and agreed upon by you or your representative within thirty (30) calendar days, the grievance will be considered resolved.
Any Mercy LIFE of Alabama participant or his/her representative may file a
grievance with any staff member at any time, either in person, by telephone or in
writing. You may do so by visiting the PACE Center, calling at 251-287-8420, mailing your grievance to:
2900 Springhill Ave
Mobile, Al 36607
Or by faxing your grievance to: 251-287-8478
Mercy LIFE of Alabama Grievance Review External Options
Any participant who completes the grievance process or who has participated in the process for at least twenty (20) days and is still dissatisfied may pursue further steps which include an external grievance review option.
If you choose to use the external grievance review process please contact:
Alabama Medicaid Office/PACE Program Unit
P O Box 5624
501 Dexter Avenue
Montgomery, Al 36103-5626
Appeal of Coverage and Payment Denials
You Have a Right to Appeal. You have a right to appeal any treatment decisions made by Mercy LIFE of Alabama or contracted providers, including decisions not to authorize or pay for items and services which you believe are covered by Mercy LIFE of Alabama.
Who May File An Appeal?
You or someone you name to act for you (your authorized representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you.
You can call Mercy LIFE of Alabama at (251) 287-8420 to learn how to name your authorized representative. If you have a hearing or speech impairment, please call the TTY number 1- 855-212-1552.
If you want someone to act for you, you and your designated representative must sign, date and send us a statement naming that person to act for you.
There Are Two Kinds of Appeals You Can File
Standard (30 days) - You can ask for a standard appeal. We must give you a written decision no later than thirty (30) days after we get your appeal.
Expedited (72-hour review) - You can request an expedited (fast) appeal if you believe that your health could be seriously harmed by waiting too long for a decision. We must decide on an expedited appeal no later than 72 hours after we receive your appeal. We may extend this time by up to fourteen (14) days if you request an extension or if we demonstrate to the State the need for additional information, the need for the extension and how it would benefit you.
What Do You Include In your Appeal?
You should include: your name, address, Member ID number, reasons for appealing, and any evidence you wish to attach. You may send in supporting medical records, doctors' letters, or other information that explains why we should provide or pay for the service or item. Call your doctor or ask for help from any staff member if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.
How Do I File An Appeal?
For a Standard Appeal: You or your authorized representative should mail or deliver your written appeal to the address below:
Mercy LIFE of Alabama
2900 Springhill Ave
Mobile, AL 36607
Attention: Mercy LIFE of Alabama Quality Assurance Coordinator
For a Fast Appeal: You or your authorized representative should contact us by telephone or fax:
Fax #: (251)-287-8478
For the hearing impaired, the TTY number is: 1- 855-212-1552.
What Happens Next?
If you appeal, we will review our decision. We will also appoint an appropriately credentialed and impartial third party, who was not involved in the original action and who does not have a stake in the outcome of the appeal, to review your appeal.
All appeal information will be kept confidential. After we review this decision, if any of the services or items you requested are still denied, additional appeal rights under Medicaid and Medicare are available.
Additional Appeal Rights Under Medicaid or Medicare
If we do not make a decision on your appeal that is in your favor, you have additional appeal rights. Your request to file an external appeal can be made either verbally or in writing. The next level of appeal involves a new and impartial review of your case through either the Medicare, Medicaid or the State Administrative Review Process. The Medicare program contracts with an "independent review organization" to provide external review on appeals involving PACE programs like us. This review organization is completely independent of our PACE organization.
The Medicaid program conducts their next level of appeal through the State's Fair Hearing process. The Alabama Medicaid Agency conducts and independent review for participants who are not eligible for Medicare or Medicaid and pay privately for PACE services.
If you are enrolled in both Medicare and Medicaid, you may choose which appeals process you will use. If you wish, we can help you choose which appeals process to follow by explaining the different processes. If you are not sure which program you are enrolled in, ask us. The Medicare, Medicaid and Alabama Medicaid Agency external appeal processes are described below.
Medicaid External Appeals Process
If you are enrolled in both Medicaid and Medicare (dually eligible) OR Medicaid only, you can choose the Medicaid appeals process. You have the right to submit your appeal at any time.
Medicaid Fair Hearing Process:
PO Box 5624
501 Dexter Ave.
Montgomery, AL 36103-5624
Medicare External Appeals Process
(Cannot be used for Denials of Enrollment or Involuntary Disenrollment appeals)
If you are enrolled in both Medicare and Medicaid (dual eligible) OR Medicare only, you may choose to appeal using Medicare's external appeals process. We will send your case file to Medicare's independent review organization (IRO) for you. The IRO will contact us with the results of their review. The IRO will either uphold our original decision or rule in your favor. Medicare beneficiaries may appeal through the external review entity under contract with CMS for all appeals except those pertaining to enrollment denials and involuntary disenrollments.
Medicare has an expedited and a standard external appeals process. You can request an expedited external appeal. Expedited Appeals process will be used in situations in which a participant or designated representative believes that his or her life, health, or ability to regain or to maintain maximum function could be seriously jeopardized, absent provision of the service in dispute. Mercy LIFE of Alabama will respond to the appeal as expeditiously as the participant’s health condition requires, but no later than seventy-two (72) hours after it receives the appeal. The IRO must give us a decision within 72 hours after they receive the appeal. If the IRO asks for more time to review the appeal, they must give us their decision within fourteen (14) calendar days.
You can request a standard appeal if we deny your request for non-urgent services or for nonpayment of a claim. For a standard external appeal, you will get a decision no later than thirty (30) days after you request the appeal.
If the IRO's decision is in your favor and you have requested a service that you have not received, we must give you the service as quickly as your health condition requires. If you have requested payment for a service that you have already received, we must pay for the service.
If this was an expedited appeal and the IRO's decision is in your favor we must give you the service as quickly as your health condition requires.
If you need information or help, call us at: (251) 287-8420
1-800-MEDICARE (1800-633-4227) TTY/TTD: 1-877-486-2048
If you are eligible for Medicare only or Private Pay you may use the Alabama Medicaid Agency's Administrative Review Process. This appeal process is also for those Medicare only eligible persons appealing a denial of enrollment or an involuntary discharge.
Administrative Review Process
Alabama Medicaid Agency
PACE Program Unit
PO Box 5624
501 Dexter Ave.
Montgomery, AL 36103-5624