Intotal health provider appeal form

FAMIS Member Appeals

FAMIS Member Appeals

An appeal is when you ask INTotal Health to look again at a decision and change a decisions INTotal Health has made on a service or a process that applies to your benefits and coverage or affects your relationship with INTotal Health. This can apply to authorizations denied for services or a prescription, or if a change to your benefits has taken place that you are not satisfied with. You, a person helping you, or your provider must file for an appeal within 30 calendar days from the date of the decision letter. If it applies, you can ask for your services to continue while you appeal the decision.

Member Appeal Process

You can appeal our decision in two ways:

• You can call Member Services at 1.855.323.5588 to begin your appeal. We will send you an Appeal form, if you request it. If you want someone else to help you with the appeal process such as a family member, friend or your provider, let us know. In addition to the Appeal form, if you want someone else to help you, you will need to fill out the Designated Representative form, which is located in your decision letter packet as well as on the INTotal Health website at www.intotalhealth.org. Fill out the Designated Representative form if needed and the written appeal form or letter and mail it back to us. You must mail it back to us within 30 calendar days from the date of the decision letter. If you ask for an expedited appeal, you may do so by phone, but you will still need to complete and send us the form. Please see the next section on how to ask for an expedited appeal.
• You can send a letter or the Appeal form (which can be found in your decision letter packet or on the INTotal Health website at www.intotalhealth.org) to the address or the fax number below. A mailing must be post-marked no later than 30 calendar days from the date of the decision letter. Include information such as the care you are looking for and the people involved, the issue affecting your relationship with INTotal Health and your signature and date. Have your provider send us your medical information about this service to:

INTotal Health
Member Appeals Unit
3190 Fairview Park Drive, Suite 900
Falls Church, VA 22042
Or
Fax: 1.888.240.4718

When we get your letter or forms, we will send you a letter within 5 business days. This letter will let you know we got your appeal request. Your appeal will be looked at by a different provider or individual than the one who made the first decision. We will send you and your provider a letter within 30 calendar days of when we get your appeal. This letter will let you and your provider know what INTotal Health decides. The letter will also tell you and your provider how to find out more about the decision and your rights to appeal to KePro, assigned to us by DMAS.

There may be times when we need more information from you or the person you asked to file the appeal for you. If we need more information, we may extend the appeals process for 14 calendar days. If we extend the appeals process, we will let you know in writing the reason for the delay. You may also ask us to extend the process if you need more time.

Expedited Appeals

You or the person you ask to file an appeal for you can request an expedited appeal. You can request an expedited appeals process if you or your provider feels that taking the time for the standard appeals process could seriously harm your life or your health. You must do this in writing within 30 calendar days from the date on the decision letter. Please send your request to:

INTotalHealth
Member Appeals Unit
3190 Fairview Park Drive, Suite 900
Falls Church, VA 22042
Or
Fax: 1.888.240.4718

When we get your letter or form, we will send you a letter with the decision about your appeal request. We will do this within 72 hours after we get your expedited appeal and all the information we need to make a decision.

If we do not agree that your request for an appeal should be expedited, your appeal will be reviewed through the standard review process.

During a grievance and/or appeal, you have the right to:

• Understand that you may be responsible for the cost of benefits if the grievance/appeal decision is determined to be the same as INTotal Health’s decision
• Request an extension for up to 14 calendar days, verbally or in writing, while the grievance/appeal is in progress
• To be contacted by INTotal Health, in writing, regarding the reason of the grievance/appeal extension; the reason for the grievance/appeal extension could be that additional information is required
• Review all papers before and during the grievance/appeal process, by written request to INTotal Health
• To include, as parties to the grievance/appeal, the legal representative of a deceased member’s estate

External Review

If you are not in agreement with the decision of INTotal Health, you may file an appeal within 30 calendar days of the date on the decision letter. A review will be conducted by KePro, whom is contracted by DMAS to process external reviews. Requests for external review cannot be submitted until after you have exhausted INTotal Health’s appeals process. Requests for external review must always be submitted in writing to:

FAMIS External Review Request
c/o KePro
2810 N. Parham Road
Suite #305

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