Schedule K Policy Appeals Processes.docx
DOCX document 19 KB Posted
- Attached to
- MPSERS Dental Benefit Plan Administration
- Solicitation number
- RFP-171-200000001290-3
- Issued by
- Grand Traverse County, Lansing City, Michigan
About this file
This is a policy document (Schedule K) from the State of Michigan outlining appeals processes for non-Medicare member benefits under the Michigan Public School Employees Retirement System (MPSERS). The policy, effective February 27, 2012, specifically governs appeals procedures for medical, prescription drug, dental, and vision benefits for non-Medicare MPSERS members. The document is referenced under RFP No. 200000001290 and explicitly notes that MPSERS is not subject to PPACA (Patient Protection and Affordable Care Act).
The appeals process is administered by respective carriers and follows a two-tier system. For medical, dental, and vision claims, members must first submit a customer inquiry, followed by a first-level appeal (grievance) with the medical vendor, and then a second-level managerial conference where members can appear in person with representation. For prescription claims, point-of-sale rejections can be appealed first through the prescription vendor, followed by a second-level managerial conference. The policy specifically notes that there is no independent level of review outside the insurance company, as the Attorney General determined PA 251 is not applicable to MPSERS self-funded plans. Members' final recourse is to contact the Office of Retirement Services (ORS) or pursue litigation.
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Text version
Policy Title:
Appeals processes for MPSERS non-Medicare member benefits for Medical and Prescription Drug
| Effective Date: |
| 02/27/2012 |
| Version: |
| 1.0 |
| Process: |
| BPD |
STATE OF MICHIGAN
RFP No. 200000001290
SCHEDULE K
Policy Appeals Processes
Purpose:
This policy governs the appeals processes to be used in the administration of the MPSERS non-Medicare member benefits. Members enrolled in CMS programs (Medicare Advantage and Part D) appeals processes are governed by different rules dictated by CMS (Medicare).
Notes:
1. This policy applies to Non-Medicare plans only.
1. This policy covers MPSERS Medical, Prescription, Dental, and Vision plans.
1. MPSERS is not subject to PPACA.
1. The appeals processes are administered by the respective carriers. Please direct member appeal requests to the appropriate carrier.
Policy:
| Appeals process for: |
| MPSERS Medical, Dental, and Vision |
| MPSERS Prescription |
| Preservice |
| None. Payment must be denied before claim can be appealed. |
| Prior Authorization and Tier Exceptions can be initiated before a claim has been rejected. |
Post Service EOB notice of denial - adverse benefit determination directs member to insurance company for first level grievance Member is directed to submit a customer inquiry first. If not the member is not satisfied with the outcome, then they are directed to appeal.
1. First level appeal is by the Medical vendor (grievance)
2. 2nd level appeal is a managerial level conference where the member can appear in person and have representation -conducted by the Medical vendor If a claim is rejected at point of sale, the pharmacist will receive a message indicating why the prescription is not covered.
Members can appeal:
1. First level appeal by Prescription vendor
2. Second level appeal is a managerial level conference where the member can appear in person and have representation - conducted by the Prescription vendor
| Does independent level of review outside the insurance company exist? |
| No. AG determined PA 251 not applicable to the MPSERS self-funded plans. The member’s next step is to contact the ORS or pursue litigation |
| No. AG determined PA 251 not applicable to MPSERS self-funded plans. The member’s next step is to contact the ORS or pursue litigation |
| Other |
| EOB and/or pre-service letter should reflect the policy described here |
| EOB and/or pre-service letter should reflect the policy described here |
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End of Document
Rev. Date:
03/25/2014
File details come from the government source that posted it. Updated .