Appeal for Medical Care

Step-by-step: How to make a Level 1 Appeal for Medical Care

How to ask for a review of a medical care coverage decision made by our plan

Step 1: You contact us and make your appeal. If your health requires a quick response, you must ask for a “fast appeal.”

What to do
  • To start an appeal you, your doctor, or your representative, must contact us.
  • If you are asking for a standard appeal, make your standard appeal in writing by submitting a request. You may also ask for an appeal by calling us.
  • If you are asking for a fast appeal, make your appeal in writing or call us.
  • You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision.
  • You can ask for a copy of the information regarding your medical decision and add more information to support your appeal.
    • You have the right to ask us for a copy of the information regarding your appeal.
    • If you wish, you and your doctor may give us additional information to support your appeal.

Method

Appeals For Medical Care – Contact Information

Call

1-866-333-3530
Calls to this number are free. Hours are 8 a.m. to 8 p.m., seven days a week from October 1 through March 31, except holidays, and 8 a.m. to 8 p.m., Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.

TTY

711
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

Fax

1-866-207-6539

Write

Vitality Health Plan of California
Member Services Department (Appeals)
18000 Studebaker, Road, Suite 960
Cerritos, CA 90703

Click here to download the Appeal form (Reconsideration Request form for Medical Care): English | Spanish | Chinese | Korean | Vietnamese

Download Adobe Acrobat Reader

For expedited requests, please call or fax using the contact numbers above.

If your health requires it, ask for a “fast appeal” (you can make a request by calling us)
  • If you are appealing a decision we made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal.”
  • The requirements and procedures for getting a “fast appeal” are the same as those for getting a “fast coverage decision.” To ask for a fast appeal, follow the instructions for asking for a fast coverage decision. (These instructions are given earlier in this section.)
  • If your doctor tells us that your health requires a “fast appeal,” we will give you a fast appeal.

Step 2: We consider your appeal and we give you our answer.

  • When our plan is reviewing your appeal, we take another careful look at all of the information about your request for coverage of medical care. We check to see if we were following all the rules when we said no to your request.
  • We will gather more information if we need it. We may contact you or your doctor to get more information.
Deadlines for a “fast appeal”
  • When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.
  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal.
  • If our answer is no to part or all of what you requested, we will automatically send your appeal to the Independent Review Organization for a Level 2 Appeal.
Deadlines for a “standard appeal”
  • If we are using the standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. We will give you our decision sooner if your health condition requires us to.
  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 calendar days after we receive your appeal.
  • If our answer is no to part or all of what you requested, we will automatically send your appeal to the Independent Review Organization for a Level 2 Appeal.

Step 3: If our plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process.

  • To make sure we were following all the rules when we said no to your appeal, we are required to send your appeal to the “Independent Review Organization.” When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2.

Step-by-step: How a Level 2 Appeal is done for Medical Care

If we say no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews our decision for your first appeal. This organization decides whether the decision we made should be changed.

Step 1: The Independent Review Organization reviews your appeal.

  • The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.
  • We will send the information about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file.
  • You have a right to give the Independent Review Organization additional information to support your appeal.
  • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal.

Step 2: The Independent Review Organization gives you their answer.

The Independent Review Organization will tell you its decision in writing and explain the reasons for it.

  • If the review organization says yes to part or all of what you requested, we must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we receive the decision from the review organization for standard requests or within 72 hours from the date the plan receives the decision from the review organization for expedited requests.
  • If this organization says no to part or all of your appeal, it means they agree with us that your request (or part of your request) for coverage for medical care should not be approved. (This is called “upholding the decision.” It is also called “turning down your appeal.”)

Step 3: If your case meets the requirements, you choose whether you want to take your appeal further.

  • There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).
  • If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. The details on how to do this are in the written notice you got after your Level 2 Appeal.
  • The Level 3 Appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

For more information on the medical care appeal process, you may refer to Chapter 9 Section 5 of the Evidence of Coverage (EOC).

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to file a grievance, request a coverage decision, or make an appeal at any level of the process. Go to “How to Appoint a Representative” page to find out more.

You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions. Please contact Vitality Member Services Department at 1-866-333-3530 (TTY: 711). Hours are 8 a.m. to 8 p.m., seven days a week from October 1 through March 31, except holidays, and 8 a.m. to 8 p.m., Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.

Last updated 12/20/2018