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Thank You for being a Member of Great Plains Medicare Advantage

Nebraska

Member Resources provides you with the tools, information and resources to help you get the most out of your Great Plains Medicare Advantage (HMO I-SNP) or Great Plains Medicare Advantage Gold (HMO I-SNP) benefits and coverage and much more.

  • To request a hardcopy of the Great Plains Medicare Advantage provider directory or the Evidence of Coverage, please call Member Services at (844)-637-4760 (TTY 888-279-1549).
  • To learn about your members rights and responsibilities, please see Chapter 8 of your:

Out of Network Coverage Rules

As a member of Great Plains Medicare Advantage, you must use network providers. If you receive unauthorized care from an out-of-network provider, we may deny coverage and you will be responsible for the entire cost.

Here are three exceptions:

  • The plan covers emergency care or urgently needed care that you get from an out- of-network provider. For more information about this, and to learn what emergency or urgently needed care means, please contact Member Services.
  • If you need medical care that 1) Medicare requires our plan to cover, and 2) the provider in our network cannot provide this care, you can get this care from an out- of-network provider. Prior Authorization should be obtained from the plan prior to seeking care. In this situation, if the care is approved, you would pay the same as you would pay if you got the care from a network provider. Your PCP or other network provider will contact us to obtain authorization for you to see an out-of- network
  • Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. In these special circumstances, it is best to ask an out-of-network provider to bill us first. If you have already paid for the covered services or if the out-of-network provider sends you a bill that you think we should pay, please contact Member Services or send us the

How to Request an Organization Determination

What is an Organization Determination?

An organization determination is any determination (i.e. approval or denial) made by a Medicare health plan (e.g., Great Plains Medicare Advantage) regarding:

  1. Receipt of, or payment for, a managed care item or service;
  2. The amount a health plan requires an enrollee to pay for an item or service; or
  3. A limit on the quantity of items or services.

You may file a standard reconsideration if you disagree with the decision that was made by Great Plains Medicare Advantage.

Who Can Request an Organization Determination?

An enrollee, an enrollee’s representative, or any provider that furnishes, or intends to furnish, services to an enrollee, may request a standard organization determination by filing an oral or written request with Great Plains Medicare Advantage. Expedited requests may be requested by an enrollee, an enrollee’s representative, or any physician, regardless of whether the physician is affiliated with Great Plains Medicare Advantage.

When Can an Organization Determination Be Requested?

An organization determination made by Great Plains Medicare Advantage can be requested with respect to any of the following:

  • Payment for temporarily out of the area renal dialysis services, emergency services, post-stabilization care, or urgently needed services;
  • Payment for any other health services furnished by a provider other than Great Plains Medicare Advantage that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by Great Plains Medicare Advantage;
  • Great Plains Medicare Advantage’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by Great Plains Medicare Advantage;
  • Reduction, or premature discontinuation of a previously authorized ongoing course of treatment; or
  • Failure of Great Plains Medicare Advantage to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee.

Where Can an Organization Determination be filed?

The way you submit an organization redetermination depends on when your service is happening. If you are requesting an organization redetermination:

Before the service is performed: This is considered an authorization request, please contact our UM dept at 1-605-312-8219 (TTY 888-279-1549), option 3

After a service is provided: This is considered a claim so you should follow the procedures above for submitting a claim.

Our plan has fourteen (14) calendar days (for a standard organization determination request) or seventy-two (72) hours (for an expedited request) from the date it gets your request to notify you of its decision.

What Is a Standard Reconsideration (i.e., Appeal)?

A reconsideration is also known as an appeal. If Great Plains Medicare Advantage denies an enrollee’s request for an item, service in whole or in part, or any amounts the enrollee must pay for a service (issues an adverse organization determination), the enrollee may appeal the decision to the plan by requesting a reconsideration.

A reconsideration consists of a review of an adverse organization determination or termination of services decision, the evidence and findings upon which it was based, and any other evidence that the parties submit or that is obtained by the health plan, the QIO, or the independent review entity.

Who can Request a Standard Reconsideration (i.e., Appeal)?

  • An enrollee or an enrollee’s appointed or authorized representative may request a standard or expedited reconsideration (i.e., appeal).
  • A non-contract physician or provider to a Medicare Health plan may request a standard reconsideration without being appointed as the enrollee’s representative, on the enrollee’s behalf.
  • Non-contract providers must include a signed Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal.
  • A physician regardless of whether the physician is affiliated with the plan may request that a Medicare Health Plan expedite a reconsideration.
  • Contract providers do not have appeal rights.

How to Request a Reconsideration

  • Reconsideration requests must be filed with the health plan within 60 calendar days from the date of the notice of the organization determination.
  • Expedited requests can be made either orally or in writing.
  • Standard requests must be made in writing unless the enrollee’s plan accepts oral requests. An enrollee should call the plan or check his or her Evidence of Coverage to determine if the plan accepts oral standard requests.

Important Things to Know About Asking for Standard Reconsideration:

A party must file the request for reconsideration within sixty (60) calendar days from the date of the notice of the organization determination. If a request for reconsideration is filed beyond the sixty (60) calendar day time frame and good cause for late filing is not provided, Great Plains Medicare Advantage will forward the request to the independent review entity for dismissal.

Once the plan receives the request, it must make its decision and notify the enrollee of its decision as quickly as the enrollee’s health requires, but no later than 72 hours for expedited requests or 30 calendar days for standard requests, or 60 calendar days for payment requests.

Our plan can accept or deny your request. If we approve your request for a standard reconsideration, our approval is valid until the end of the plan year.

Where Can a Reconsideration Be Filed?

You or your representative can request a reconsideration by writing directly to us at:

  • Great Plains Medicare Advantage – Appeals and Grievances
    Department, P.O. Box 91110 Sioux Falls, SD, 57109
  • Fax: 1-605-312-8217
  • Contact Member Services Department at our toll-free number at 1-844-637-4760 (TTY 888-279-1549).

What is a Good Cause Exception?

If a party shows good cause, Great Plains Medicare Advantage may extend the time frame for filing a request for reconsideration (i.e., appeal). Great Plains Medicare Advantage will consider the circumstance that kept the enrollee or representative from making the request on time and whether any organizational actions might have misled the enrollee.

Examples of circumstances where good cause may exist to file a late appeal include (but are not limited to) the following situations:

  • The enrollee did not personally receive the adverse organization determination notice, or he/she received it late;
  • The enrollee was seriously ill, which prevented a timely appeal;
  • There was a death or serious illness in the enrollee’s immediate family;
  • An accident caused important records to be destroyed;
  • Documentation was difficult to locate within the time limits;
  • The enrollee had incorrect or incomplete information concerning the reconsideration process; or
  • The enrollee lacked capacity to understand the time frame for filing a request for reconsideration.

How to File an Appeal

What Is an Appeal?

An appeal is a formal request by the member (or his/her authorized representative) to change a decision previously made by Great Plains Medicare Advantage.

For example, you may file an appeal for any of the following reasons:

  • Great Plains Medicare Advantage refuses to cover or pay for services you think Great Plains Medicare Advantage should cover.
  • Great Plains Medicare Advantage or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
  • Great Plains Medicare Advantage or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
  • If you think that Great Plains Medicare Advantage is stopping your coverage too soon.

Who Can File an Appeal?

You or your authorized representative may file an appeal. You may also have your physician file an appeal on your behalf.

You may appoint an individual to act as your representative to file the grievance or an appeal for you by following the steps below.

Provide our health plan with:

  1. Your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: “I [your name] appoint [name of representative] to act as my representative in requesting an appeal from Great Plains Medicare Advantage and/or CMS regarding the denial or discontinuation of medical services.”
  2. Your name, address and phone number and that of your representative, if applicable.
  3. A signed and dated statement by you and the person you are appointing as representative
  4. You must include this signed statement with your appeal.
  5. Reasons for appealing, and any evidence you wish to attach.
  6. Supporting medical records, doctors’ letters, or other information that explains why your plan should provide the service. Call your doctor 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.

When Can an Appeal Be Filed?

You may file an appeal within sixty (60) calendar days of the date of the notice of the initial organization determination.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day time frame.

Can I Expedite an Appeal?

Yes, you may file an expedited grievance by calling: 1-844-637-4760 (TTY 888-279-1549), option 6.

You have the right to request and receive expedited decisions affecting your medical treatment in “time-sensitive” situations.

A “time-sensitive” situation is a situation where waiting for a decision to be made within the time frame of the standard decision-making process could seriously jeopardize 1) your life or health, or 2) your ability to regain maximum function.

If Great Plains Medicare Advantage decides, based on medical criteria, that your situation is “time-sensitive” or if any physician calls or writes in support of your request for an expedited review, Great Plains Medicare Advantage or your Primary Care Physician will issue a decision as expeditiously as possible, but no later than seventy-two
(72) hours after receiving the request.

Where Can an Appeal Be Filed?

You may file a standard or fast appeal to: Great Plains Medicare Advantage, Appeals and Grievances Department, PO Box 91110, Sioux Falls, SD, 57109, Phone 1-844-637-4760 (TTY 888-279-1549) , Fax 1-605-312-8217.

What Happens Next?

We will review your appeal. If any of the services you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by a reviewer outside of Great Plains Medicare Advantage. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.

How to File a Grievance

What Is a Grievance?

A grievance is a type of complaint that does not involve payment or denial of services by Great Plains Medicare Advantage or a Contracting Medical Provider. For example, you would file a grievance if:

  • You have a problem with things such as the quality of your care during a hospital stay;
  • You feel you are being encouraged to leave your plan;
  • Waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room;
  • Waiting too long for prescriptions to be filled;
  • The way your doctors, network pharmacists or others behave;
  • Not being able to reach someone by phone or obtain the information you need; or
  • Lack of cleanliness or the condition of the office.

Who Can File a Grievance?

A grievance may be filed by any of the following:

  • You may file a grievance.
  • Your authorized representative.

Why File a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with Great Plains Medicare Advantage or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding, or lack of information.

Can I Expedite a Grievance?

Yes, you may file an expedited grievance by calling: 1-844-637-4760 (TTY 888-279-1549).

Where can a Grievance Be Filed?

You may file a standard grievance in writing directly to: Great Plains Medicare Advantage -Appeals and Grievances Department, PO Box 91110 Sioux Falls, SD, 57109 or by faxing 1-605-312-8217 or over the phone by contacting our Member Services Department at our toll-free number at 1-844-637-4760 (TTY 888-279-1549). Download the form here.

If you would like you can file a complaint directly to Medicare by filling out the complaint form at https://www.medicare.gov/MedicareComplaintForm/home.aspx.

How to Obtain an Aggregate Number of Appeals, Grievances and Exceptions

You have the right to request the number of appeals and the number of quality of care grievances received by Great Plains Medicare Advantage during a plan year.

Please call Member Services at 1-844-637-4760 (TTY 888-279-1549).

How to Appoint a Representative to File a Grievance or Complaint

You or someone you name may file a complaint (grievance) or appeal for you. The person you name would be your “appointed representative”. You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act on your behalf.

To appoint a representative, fill out the CMS Appointment of Representative Form (CMS Form-1696)Once you have filled out the form, you may print and mail the form to:

Great Plains Medicare Advantage
PO Box 91110
Sioux Falls, SD, 57109
You may also send a fax to 1-605-312-8217

A description of, and information on how to appoint a representative, you may also call Member Services for Great Plains Medicare Advantage at 1-844-637-4760 (TTY 888-279-1549).

How to End Your Great Plains Medicare Advantage Benefits

Ending your Membership in Great Plains Medicare Advantage may be voluntary (your own choice) or involuntary (not your own choice). If you are leaving our plan, you must continue to get your medical care through our plan until your Membership ends.

For more complete information about disenrolling from Great Plains Medicare Advantage, you can do any of the following:

  • See chapter 8 of your Evidence of Coverage for more information and to learn about the rights, benefits, and responsibilities of Members.
  • To request a disenrollment form, call Great Plains Medicare Advantage at 1-844-637-4760 (TTY 888-279-1549). Calls to this number are free.
  • Read the Medicare & You Handbook. Everyone with Medicare receives a copy of Medicare & You each fall. Those new to Medicare receive it within a month after first signing up. You can also download a copy from the Medicare website (www.Medicare.gov). Or, you can order a printed copy by calling Medicare at the number below.
  • Contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Calls to these numbers are free.

Prescription Drug Benefit

Great Plains Medicare Advantage provides Medicare Part D prescription drug coverage through our partner Navitus Health Solutions. Navitus Health Solutions is a full-service pharmacy benefit management company committed to lowering drug costs, improving health, and providing superior customer service in a manner that instills trust and confidence.

Together, we make it easier for you to follow your doctor’s orders related to your health care and prescription drug use. For your convenience, there is a complete list of all covered drugs in the plan (a comprehensive formulary). See other list of covered drugs (Formulary) here for Great Plains Medicare Advantage I-SNP, and here for Great Plains Medicare Advantage I-SNP GOLD.

Our formulary is designed to cover the drugs most needed to treat the special needs of our Members. If the drug you are taking is not on the list of covered drugs, read your Prescription Drug Transition Policy and Evidence of Coverage, located in your member materials below, to find out what you can do. This includes instructions for both new and current Members. If you would like help managing your prescription drugs, read about our Medication Therapy Management program and its eligibility requirements. Need to find a participating pharmacy near you? Click here to search our Pharmacy Directory.

How to Request a Coverage Determination

What Is a Coverage Determination?

A coverage determination is decision made by our plan (not the pharmacy) about your prescription drug benefits, including whether a particular drug is covered, whether you have met all the requirements for getting a requested drug, how much you’re required to pay for a drug, and whether to make an exception to a plan rule when you request it.

What Is an Exception?

If a drug is not covered on our plan, you can ask the plan to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.

Who Can Request a Coverage Determination / Exception?

A coverage determination may be requested by any of the following:

  • You or your representative may request a coverage determination.
  • Your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) can request a coverage determination for you on your behalf.

When Can a Coverage Determination/ Exception Be Requested?

A coverage determination may be requested for any of the following:

  • Covering a Part D drug for you that is not on our plan’s List of Covered Drugs (Formulary).
    • You may ask our plan for an exception if you or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) believes you need a drug that isn’t on your drug plan’s list of covered drugs.
    • You may ask for an exception if your network pharmacy can’t fill a prescription as written.
  • Removing a restriction on the plan’s coverage for a covered drug.
    • You may ask for an exception if you or your prescriber believe that a coverage rule (such as a prior authorization) should be waived.
  • Changing coverage of a drug to a lower cost-sharing tier. (Tier Exception)
    • You may ask for an exception if you think you should pay less for a higher tier drug because you or your prescriber believe you can’t take any of the lower tier drugs for the same condition.
  • Request for payment.
      • You may ask us to pay for a prescription that you already paid for.

Important Things to Know About Asking for Exceptions:

Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include medical information from your doctor or other prescriber when you ask for the exception.

Our plan can accept or deny your request.

If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true if your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. If your health requires a quick response, you must ask us to make a “fast decision”.

Where Can a Coverage Determination/Exception Be Filed?

To request a Medicare Prescription Drug Coverage Determination visit Navitus to login and access the form or A Member, a Member’s representative, or a Member’s prescriber may use this model form to request a coverage determination, including an exception, from Great Plains Medicare Advantage.

To request a Medicare Prescription Drug Redetermination (Appeals) visit Navitus to login and access the form or A Member, a Member’s representative, or a Member’s prescriber may use this model form to request a redetermination from Great Plains Medicare Advantage.

You or your representative can request an exception by writing directly to us at Great Plains Medicare Advantage – Appeals and Grievances Department, PO Box 2190 Glen Allen, VA 23058- 2190, faxing us at 1-833-610-2380, emailing customerservice@greatplainsmedicareadvantage.com, or contacting our Member Services Department at our toll free number at 1-844-637-4760.

You may also contact our Member Services Department and request the facsimile number for Appeals and Grievances.

Your provider may also request an exception or expedited exception by contacting the Pharmacy Help Desk at 1-866-270-3877 (TTY 888-279-1549) 24 hours a day, and 7 days a week.

Our plan has seventy-two (72) hours (for a standard request) or twenty-four (24) hours for an expedited request) from the date it gets your request to notify you of its decision.

Prescription Drug Coverage Forms

This section provides specific information of particular importance to our Great Plains Medicare Advantage Plan Members receiving Part D drug benefits. Below are links to forms applicable to Part D grievances, coverage determinations (including exceptions) and appeals processes

Request for a Medicare Prescription Drug Coverage Determination

A Member, a Member’s representative, or a Member’s prescriber may use Request for a Medicare Prescription Drug Coverage Determination Form to request a coverage determination, including an exception, from Great Plains Medicare Advantage.

Request for a Medicare Prescription Drug Redetermination (Appeals)

A Member, a Member’s representative, or a Member’s prescriber may use Request for a Medicare Prescription Drug Redetermination Form to request a redetermination (appeal) from Great Plains Medicare Advantage.

Request for Reconsideration of Medicare Prescription Drug Denial

A Member or a Member’s representative may use Request for Reconsideration of Medicare Prescription Drug Denial Form to request a reconsideration with the Independent Review Entity.

Best Available Evidence Policy

 

Federal regulations at 42 CFR § 423.800 specify the requirements of Part D sponsors in the administration of the low-income subsidy program, including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary’s correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan.

To address these situations, CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information is not accurate.

For more information, please view the best available evidence (BAE) policy.

Can’t find what you are looking for or need to check the status of your request?

For more information, please call us at:

Great Plains Medicare Advantage
1-844-637-4760 (TTY 888-279-1549)

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