HMO Guide for Seniors - Office of the Patient Advocate - State of ...

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Questions & Answers
How can I learn more about
appeals?
Look in your HMO’s Evidence
of Coverage or plan handbook.
Or call your HMO or HICAP.
Can I file an appeal to get a
drug I need?
Yes, if you have prescription
drug coverage. In general, the
kind of service you want must
be a covered benefit.
My HMO says it doesn’t
cover the cancer treatment
I want. What can I do?
Ask a doctor to help you file
an appeal with your HMO.
The doctor does not have to
be part of your HMO.
things you can do
How to Appeal if a Treatment Is Denied, Delayed,
or Stopped
File an appeal with your HMO. Call your HMO for
an appeal form. Or look on its website.
Your HMO must reply in 7 days, or 3 days for an
expedited or urgent appeal.
Ask a doctor to help you. He must show that it
would be seriously harmful to deny or delay your
care. The doctor does not have to be part of your
plan. Call HICAP for help.
How to Appeal a Problem with a Bill
After you send your bill for payment, your HMO
has 60 days to review it.
If your HMO will not pay your bill, you have 60
days to appeal.
The HMO has 60 days to respond to your appeal.
If it still says no, call HICAP.
How to Appeal if a Drug You Need Is Not Covered
You or your doctor can call your plan and ask it to
cover the drug. This is called an exception request.
If you need the drug urgently, your doctor can ask
for an expedited or fast review.
Your HMO must call you with a decision in 3 days,
or 24 hours for an expedited review. Call HICAP.
where to find help
HICAP (Health Insurance Counseling & Advocacy)
Free information and assistance with appeals
1-800-434-0222 www.aging.ca.gov/hicap
HSAG (Health Services Advisory Group)
Help with discharge appeals
1-800-841-1602 www.hsag.com