Member Resources

As a member of American Health Advantage of Pennsylvania, 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 provider.
• 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 bill.

What is an Organization Determination?

An organization determination is any determination (i.e. approval or denial) made by a Medicare health plan (e.g., American Health Advantage of Pennsylvania) 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 the American Health Advantage of Pennsylvania.

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 the American Health Advantage of Pennsylvania. Expedited requests may be requested by an enrollee, an enrollee’s representative, or any physician, regardless of whether the physician is affiliated with American Health Advantage of Pennsylvania.

When Can an Organization Determination Be Requested?

An organization determination made by American Health Advantage of Pennsylvania 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 American Health Advantage of Pennsylvania that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the American Health Advantage of Pennsylvania;
• American Health Advantage of Pennsylvania’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 American Health Advantage of Pennsylvania;
• Reduction, or premature discontinuation of a previously authorized ongoing course of treatment; or
• Failure of American Health Advantage of Pennsylvania 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?

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 American Health Advantage of Pennsylvania 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 180 calendar days / (60) day limit (Non-Participating Providers) 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 180 calendar days / (60) day limit (Non-Participating Providers) from the date of the notice of the organization determination. If a request for reconsideration is filed beyond the 180 calendar days / (60) day limit (Non-Participating Providers) time frame and good cause for late filing is not provided, American Health Advantage of Pennsylvania 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:

• American Health Advantage of Pennsylvania – Appeals and Grievances Department, 201 Jordan Road, Suite 200, Franklin, TN 37067
• Fax: 1-844-280-5360
• Email: memberservices@amhealthplans.com
• Contact Member Services Department at our toll-free number at 1-855-239-1022; TTY 1-833-312-0046. Our hours are between 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

What is a Good Cause Exception?

If a party shows good cause, American Health Advantage of Pennsylvania may extend the time frame for filing a request for reconsideration (i.e., appeal). American Health Advantage of Pennsylvania 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

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 American Health Advantage of Pennsylvania. For example, you may file an appeal for any of the following reasons:

• American Health Advantage of Pennsylvania refuses to cover or pay for services you think American Health Advantage of Pennsylvania should cover.
• American Health Advantage of Pennsylvania or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
• If you think that American Health Advantage of Pennsylvania 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 American Health Advantage of Pennsylvania 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 180 calendar days / (60) day limit (Non-Participating Providers) of the date of the notice of the initial organization determination.

Note: The 180 calendar days / (60) day limit (Non-Participating Providers) 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?

You have the right to request and receive expedited decisions affecting your medical treatment in “time-sensitive” situations. This will be considered a fast appeal.

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 American Health Advantage of Pennsylvania or your Primary Care Physician 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, American Health Advantage of Pennsylvania 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: American Health Advantage of Pennsylvania, Appeals and Grievances Department, 201 Jordan Road, Suite 200, Franklin, TN 37067, Phone: 1-855-239-1022; TTY 1-833-312-0046; Fax: 1-844-280-5360.

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 American Health Advantage of Pennsylvania. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.

What Is a Grievance?

A grievance is a type of complaint that does not involve payment or denial of services by American Health Advantage of Pennsylvania 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 American Health Advantage of Pennsylvania or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding, or lack of information.

Can I Expedite a Grievance?

Yes. If you disagree with American Health Advantage of Pennsylvania’s decision to extend the timeframe on your organization determination or reconsideration, or American Health Advantage of Pennsylvania’s decision to process your expedited request as a standard request. In such cases, you may file an expedited grievance and receive a response within twenty-four (24) hours of receipt.

Where can a Grievance Be Filed?

You may file a standard grievance in writing directly to: American Health Advantage of Pennsylvania Appeals and Grievances Department, 201 Jordan Road, Suite 200, Franklin, TN 37067 by faxing 1-844-280-5360 or over the phone by contacting our Member Services Department at our toll-free number at 1-855-239-1022; TTY 1-833-312-0046. Our hours are between 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

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.

You have the right to request the number of appeals and the number of quality of care grievances received by American Health Advantage of Pennsylvania (HMO I-SNP) during a plan year. Please call Member Services at 1-855-239-1022; TTY 1-833-312-0046.

Our hours are 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Calls to this number are free.

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 Form1696). Once you have filled out the form, you may print and mail the form to:

American Health Advantage of Pennsylvania
201 Jordan Road, Suite 200
Franklin, TN
You may also send a fax to 1-844-280-5360

A description of, and information on how to appoint a representative, you may also call Member Services for American Health Advantage of Pennsylvania at 1-855-239-1022; TTY 1-833-312-0046. Our hours are 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Calls to this number are free.

Ending your Membership in American Health Advantage of Pennsylvania 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 American Health Advantage of Pennsylvania, you can do any of the following:

• See your Evidence of Coverage, Chapter 10 for more information and to learn about the rights, benefits, and responsibilities of Members.
• You can make a disenrollment request in writing to us. Contact American Health Advantage of Pennsylvania at the number below if you need more information on how to make your request in writing to us or you may download the Disenrollment Form and mail your completed Disenrollment Form to us.
• To request a disenrollment form, call American Health Advantage of Pennsylvania at 1-855-239-1022; TTY 1-833-312-0046. Calls to this number are free. Our hours are 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.)
• 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.