GRIEVANCES AND APPEALS

Our Participant Grievance and Appeal Process is outlined below.

I. Grievance Process
A grievance is defined as a written or oral expression of dissatisfaction with service delivery or quality of care furnished. VOANS Senior CommUnity Care of North Carolina shares the responsibility for assuring you are satisfied with the care you receive.

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We understand that sometimes there are areas of dissatisfaction that require our attention and response. If you are dissatisfied, we encourage you to express any complaints or concerns you may have. If you do not speak English, a staff member, professional, or volunteer who speaks your language will facilitate the grievance process.

 

SCCNC will discuss the grievance with you and provide you with written information about the specific steps that will take place to resolve your grievance. You can discuss your concerns or send a letter expressing them to any member of the staff or administration of SCCNC. All services will be continued during the grievance process.

 

The staff member who receives your grievance will forward it to the SCCNC Quality Assurance Department and see that action is taken. You will receive a written acknowledgment of the grievance within five (5) working days of receiving it.

 

If a solution is found by the staff and agreed upon by you, your family, or significant other within thirty (30) working days, the grievance will be considered resolved.

 

If you are not satisfied with the outcome, you may take your grievance to the Executive Director or send it in writing to:

 

Executive Director

 

VOANS Senior CommUnity Care of North Carolina
4022 Stirrup Creek Drive, Suite 315
Durham, NC 27703

 

This must be done within thirty (30 days) of the final decision of your original grievance.

 

The SCCNC Executive Director will send a written acknowledgment of receipt of the grievance within five (5) business days to you, your family, or your significant other. The SCCNC Executive Director will then investigate and take action.

 

The grievance should be resolved within thirty (30) days from the date it was received by the SCCNC Executive Director. Following the resolution of the grievance, a copy of the report will be sent to you or your representative.

II. Appeals Process
An appeal is defined as a participant’s and/or representative action concerning VOANS Senior CommUnity Care of North Carolina non-coverage of or non-payment for denials, reductions, or termination of services.

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VOANS Senior CommUnity Care of North Carolina’s decision to involuntary disenroll a participant may also be appealed.

 

You have a right to appeal a denial of enrollment and/or treatment decisions made by VOANS Senior CommUnity Care of North Carolina or its contracted Providers, including decisions not to authorize or pay for items and services which you believe are covered by VOANS Senior CommUnity Care of North Carolina.

 

You may request an appeal at any time by simply telling an employee, telephoning the PACE Center at (919-425-3000), or by writing a letter and mailing/faxing it to:

 

Quality Assurance Manager

 

VOANS Senior CommUnity Care of North Carolina
4022 Stirrup Creek Drive, Suite 315
Durham, NC 27703
(Fax No. 919-425-3001)

 

A written description of the appeals process will be reviewed with you or your representative at enrollment, at least annually, and any time the Team denies any request for service or payment. The written information will explain how long it will take to decide on your appeal and what factors will be considered in the decision. You will be assisted to complete an appeal by VOANS Senior CommUnity Care of North Carolina if you choose to do so.

 

VOANS Senior CommUnity Care of North Carolina will continue to furnish the disputed services until issuance of the final determination if the following conditions are met:
A. VOANS Senior CommUnity Care of North Carolina proposes to terminate or reduce services currently being furnished to the participant;
B. You may request continuation with the understanding that you may be liable for the costs of the contested services if the determination is not made in your favor.

 

VOANS Senior CommUnity Care of North Carolina will continue to furnish you with all other required services during the appeals process. There will be no discrimination by VOANS Senior CommUnity Care of North Carolina against you because you or your representative filed an appeal.

 

Participant requests for appeal will be treated by all VOANS Senior CommUnity Care of North Carolina employees in a confidential manner and violations of confidentiality will result in disciplinary action.
How to File an Appeal:

 

You or someone you name to act for you may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you.

 

If you appeal, we will appoint an appropriately credentialed impartial third party who was not involved in the original action and who does not have a stake in the outcome of the appeal to review your appeal.

 

All appeals will be resolved as expeditiously as is required by the condition of your health, but no later than 30 days from our receipt of your appeal. You will have the opportunity to present additional evidence on your case, in person, as well as in writing.

 

If the appeal is resolved in your favor, VOANS Senior CommUnity Care of North Carolina will provide or pay for the disputed service immediately. You will be notified verbally and in writing of the decision.

 

If you believe that your life or health will be in immediate danger if you do not receive the service denied, your appeal will be expedited.

 

If your appeal is expedited, VOANS Senior CommUnity Care of North Carolina will respond within 72 hours of receipt of your appeal. If your health condition allows and we can show you that we need more time to review the case, we may take up to 14 days to decide on your expedited appeal.

 

If the credentialed impartial third party does not find in your favor, you have additional appeal rights through Medicaid or Medicare. If the decision is not made in your favor, SCCNC must notify you, the Center for Medicare and Medicaid Services, and the state Medicaid Agency in writing.

 

Additional Appeal Rights under Medicaid or Medicare
If you choose, you may file an appeal under Medicare or Medicaid, SCCNC will help you or your representative to file an appeal for either.

 

The process you choose depends upon whether you are eligible for Medicaid, Medicare, and Medicaid (dually eligible) or Medicare only. If you are enrolled in both Medicaid and Medicare (dually eligible), or Medicaid ONLY, you can appeal at any time during the appeals process using the State of North Carolina’s Fair Hearing Process by contacting:

 

Office of Administrative Hearings (OAH)
Attention: Clerk of Court
6714 Mail Service Center
Raleigh, NC 27699-6714
Office: (919) 431-3000
Fax: (919) 431-3100

 

You or your authorized representative must send a written appeal request within 30 days of the date of the adverse notification.

 

Your appeal must be postmarked or received by OAH within 30 days of the adverse decision.

 

If you file an appeal before the effective date of this action, services may continue during the appeal process.

 

However, if the decision by OAH is not in your favor, you may be required to reimburse the VOANS program for the cost of services paid on your behalf during the appeal period.

 

If you wish to file an appeal, we will assist you with the forms. We will forward the adverse notice you received to OAH along with the DMA Form #2003 “Medicaid Services Recipient Hearing Request Form. If you wish to inquire about the status or progress of the appeal, you may call 919-855-4350 or you may send a fax to 919-733-2796.

 

If the decision is in your favor, we will provide or pay for the service(s) in question as quickly as your health requires, but no more than 30 days after the decision.

 

If you are eligible for Medicare only and you choose to appeal, the appeal must be made to the Medicare Independent Review Entity (IRE). We will send your appeal to that agency for you.

 

If Medicare’s decision is in your favor, we will continue to provide or pay for the service(s) in question as quickly as your health requires, but no more than 30 days after the decision.

 

If you want to appeal a denial of enrollment or disenrollment, you must appeal to the North Carolina Office of Administrative Hearings at the above address.

Last Updated on November 16, 2020 by admin