It is the policy of LIFE PACE that all participants have access to and understand their rights to file an appeal, to be assured of confidentiality, and be free of reprisal during and after the filing of an appeal. There shall be no discrimination of a participant for filing an appeal.

The purpose of the appeal procedure is to provide a fair and timely process to address written or oral appeals filed by participants, their families, or authorized representatives.

An appeal is a participant's action taken with respect to LIFE PACE' non-coverage of, or nonpayment for, a service, including denials, reductions, or termination of services.

All written or oral appeals will receive a first response within 72 business hours, and a final decision on the appeal within 30 days of the receipt of the written or verbal appeal, or as soon as the participant's health condition demands. A request for an expedited review will be completed within 72 hours as outlined in this section.

Notice
We encourage you to use LIFE PACE' internal grievance process so that we may address your concerns as soon as possible; however, Oklahoma Medicaid recipients enrolled in LIFE PACE may appeal the decision in writing directly to:

Oklahoma Health Care Authority
Grievance Docket Clerk
Legal Division
P.O. Drawer 18497
Oklahoma City, OK 73154-0497

You or your authorized representative must send a written appeal request within 30 days of receipt of this notification. If you file an appeal before the effective date of this action, you may receive services during the appeal process. However, if this action is upheld by the Appeals Division, you may be required to reimburse the LIFE PACE program for services paid on your behalf during the appeal period.

Please include a copy of the appeal outcome notification, sign the appeal request, and mail it to:

Oklahoma Health Care Authority
Grievance Docket Clerk Legal Division
P.O. Drawer 18497
Oklahoma City, OK 73154-0497

Procedure
You, your family member/ caregiver, or authorized representative may inform any LIFE PACE employee at any time you wish to file an appeal. The appeal may be made verbally or in writing.

The center receptionist shall forward any incoming appeals via telephone to the center manager or, in his/her absence, to the social worker.

If you call the center after hours, the person on call will take your name and information about what you are appealing. He/ she will then communicate this information to the LIFE PACE social work coordinator and/or QAPI coordinator the next business day.

Upon receipt of your appeal, the PACE program social work coordinator and/or QAPI coordinator will forward a letter to you, your family/caregiver, or authorized representative to inform you of the following: 

Your appeal information will be submitted to an impartial third party appeals review committee which will review the appeal within the specified 30-day timeframe, or as soon as the your health condition demands.

You will be provided the opportunity to present evidence both verbally and in writing as it relates to the appeal.

If you are a Medicaid recipient, LIFE PACE will continue to furnish the disputed service(s) until a final determination is reached so long as 1) LIFE PACE is proposing to terminate or reduce services currently being furnished to you, or 2) you request continuation of the disputed service(s) with the understanding that you may be liable for the costs of the service(s) if the final appeals decision is not in your favor.

That all other required services will continue to be furnished to you during the appeal.

That you may receive assistance in completing the appeal.

All information related to an appeal will be held in strict confidence and will not be disclosed to individuals without a need to know to assure participant confidentiality.

If you are unhappy with the outcome of LIFE PACE' appeal review, you have additional appeal rights under Medicaid and Medicare, and LIFE PACE will assist you in contacting one of the following agencies:

Medicaid Appeals Contact: You may appeal the decision in writing directly to the Department of Department Oklahoma Health Care Authority, Legal Division Grievance Docket Clerk. You or your authorized representative must send a written appeal request within 30 days of receipt of this notification. If you file an appeal before the effective date of this action, you may receive services during the appeal process. However, if this action is upheld by the Appeals Division, you may be required to reimburse the LIFE PACE program for the cost of services paid on your behalf during the appeal period. Please include a copy of the appeal outcome notification, sign the appeal request, and mail it to: Department Oklahoma Health Care Authority, Grievance Docket Clerk, Legal Division, P.O. Drawer 18497, Oklahoma City, OK 73154-0497.

Medicare Appeals Contact: If you are eligible for Medicare, you may file an appeal to the contracted agency that handles Medicare appeals. If the appeal is ruled in your favor, the QAPI coordinator will inform all involved parties verbally and in writing of the final ruling, and direct that services are to continue or start as soon as your health condition requires.

o When an appeal is ruled not in your favor, either wholly or partially, the social worker will promptly contact, in writing, the Oklahoma Health Care Authority, Centers for Medicare and Medicaid Services (CMS), you and your family/ caregiver, or your authorized representative. A letter will be sent to you that will inform you of your additional appeal rights under Medicaid or Medicare managed care, or both, and offer assistance to you in choosing which appeals process to pursue, if both are applicable, and will forward the appeal to the agency you choose. You will be contacted by the external review agency when a decision has been reached. The decision of the external review organization is final. If the ruling is in your favor, LIFE PACE will continue, provide, or pay for the appealed service as soon as your health condition demands. If the ruling is not in your favor, LIFE PACE will discontinue the service, and/or request repayment for cost of services provided that were being appealed.

Expediated Review
If you, your family/caregiver, or authorized representative believe that waiting to solve the problem for 30 days will seriously harm your health or ability to function, an expedited review may take place. This review takes only 72 hours. This can only be used in cases where health services, or payment of services, are refused or discontinued.

To request the expedited review, you need to tell us you want a 72-hour appeal review. There are four ways to tell us you want the 72-hour review:

You may tell any LIFE PACE employee at any time; they will be sure to document your request and get it to the appropriate person.

You may call (918) 949-9969, and tell the social worker, LIFE PACE program director, or center manager you would like a 72-hour or fast appeal review.

You may fax your written appeal to (918) 585-9266.

If you prefer to make your appeal in writing, please mail or have it delivered to the attention of:

LIFE PACE
902 East Pine Street
Tulsa, OK 74106

The 72-hour process will not begin until the request is received. LIFE PACE will document in writing all verbal requests. You will receive a response within 72 hours.

You may request an extension of time for the 72-hour review of your appeal. If you decide that you need more time, please contact us by one of the options listed above, by talking to the social worker. LIFE PACE program director, or center manager, calling (918) 949-9969; writing; or faxing (918) 585-9266.

Note: We can only extend the 72-hour review for up to 14 calendar days for either of the following reasons:

Participant requests the extension.

LIFE PACE justifies with the Oklahoma Health Care Authority the need for additional information, and the delay is in the best interest of the participant.