CUP providers want to give you the best health care they can. There are times when you may not be happy with your service. There are times when CUP may deny you or your doctor’s request for a service or payment for a claim. The grievance process is a way for you to tell us about your concerns. The appeal process is a way for you or your doctor to ask CUP to review the denial of a service or a claim for payment.
Grievance Process
If you are ever not happy with your service from CUP, your doctor, or clinic staff, you can call or write to CUP to tell us about it. We will look into the problem and try to fix it. If you need help telling us about your problem, we will give you any help you need. We will call you or send you a letter within five days of hearing about your concern. If your problem involves a doctor or other health care provider, we will have another doctor look into the problem and try to fix it for you. We will let you know about our plans to fix the problem within 30 days.
To tell us about a problem, you can call or write to Member Services at:
CUP Member Service Department
19120 SE 34th St., #201
Vancouver, WA 98683
Telephone (360) 891-1520, (800) 315-7862 or Fax (360) 449-8881
Appeal Process
An Appeal is a request from you for CUP to review and reconsider a denial of services. If you have a notice from us that a referral or claim has been denied, you may ask for an appeal. You do not have to file a grievance before you ask for an appeal. You have 90 days from the date on the denial notice to ask for an appeal. Our Member Services Department will help you through each step of the appeal process and provide any help you may need.
To ask for an appeal, you may call or write to Member Services:
CUP Member Service Department
19120 SE 34th St., #201
Vancouver, WA 98683
Telephone (360) 891-1520, (800) 315-7862 or Fax (360) 449-8881
Privacy -- All of your information will be kept private and CUP will only use your medical information as we need to in order to process your grievance or appeal.
There are four levels of appeal that you may ask for. First, you can appeal to CUP. Then, if you are not happy with the results of that, you may request a Hearing from DSHS. If you are still not happy with the results, you may ask CUP to have an Independent Review Organization (IRO) review your case. Finally, if you are still not happy with the results, you may ask DSHS to have the Board of Appeals to review your case.
At any of these four levels, if you or your doctor thinks using the normal timelines may harm your health, you may ask that this step of the process be done faster. We have 72 hours from the time you request an expedited appeal, hearing, IRO, or Board of Appeals hearing to make a decision. If CUP or DSHS feels your health will not be harmed, we will let you know by phone and by letter that your appeal will go through the standard process instead of the expedited process. If we don’t agree to an expedited review, you can file a grievance by calling Member Services.
Your Rights: At any of the four levels, you may
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Present evidence on your own behalf, either in person or in writing
- Review your case file at any time
- Ask your doctor or someone else to speak for you
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Ask to continue getting services that we approved and then denied at a later date. (Note: See “Continued Services” on next page for shorter timelines you must follow)
First Level, Appeal: You or someone else on your behalf may ask for an appeal by phone, in person, or in writing. Your doctor may ask for an appeal if you give your permission in writing.
You must ask for an appeal within 90 days of the date on your notice of denial. Within 5 days, we will send you a letter to let you know we got your request for appeal. If we have a working phone number for you, we will also call you on the phone to talk about your appeal.
We will review your case and notify you of our decision in writing and by phone if we have a phone number for you. This process takes around 14 days. If it will take us longer than 14 days, we will send you a letter telling you we need more time. We will do our best to finish the process in less than 30 days.
Level Two, Fair Hearing: If you are not happy with the results of your appeal, you have the right to ask DSHS for a Hearing. After the appeal is done, you have 90 days from the date of the appeal notice to ask for a Hearing.
To ask for a Hearing with DSHS:
1. talk to the Hearing coordinator at your Community Service Office (CSO), or
2. call the Office of Administrative Hearings at (800) 583-8271, or
3. write to the Office of Administrative Hearings, PO Box 42489, Olympia WA 98504.
You must complete CUP’s appeal process before you can request a Hearing. DSHS will need to know all the details of your case. They will need to know what was denied, when it was denied, and the result of your appeal. You have a right to have someone speak for you at the hearing. CUP may also speak at the hearing. If you ask, DSHS can give you a list of free legal clinics in your area that may provide you with free legal counsel (attorney help) at the hearing.
Level Three, Independent Review: After the Hearing, if you are still not happy with the results, you have the right to ask CUP to have an Independent Review Organization (IRO) review your case. To ask for an IRO review, you should contact CUP’s Member
Services Department within 60 days from the date of the Hearing decision.
CUP will send your case to the IRO within 3 working days of your request. The IRO usually makes a decision within 15 calendar days. CUP will let you know the decision of the IRO.
Level Four, Board of Appeals: If you are still not happy with the decision of the IRO, you have the right to ask the DSHS Board of Appeals to review your case. You only have 21 days from the date of the IRO decision to ask for a Board of Appeals review. To do this, write to DSHS Board of Appeals, PO Box 45803, Olympia, WA 98504-5803, or call 1-877-351-0002.
Continued Services: Sometimes you might get a denial for some services we already approved. We might decide to end, suspend, or reduce some of these services. If we do this, you have a right to keep getting those services during the appeal process until the original approved service is completed. You must tell us that you want to keep getting the services while you wait for the results of the appeal process.
You only have 10 days to file your appeal, request a hearing, IRO or Board of Appeals review and ask that services be continued.
You will have to pay for the services you received if CUP’s decision is not changed by the Appeal, Hearing, IRO, or Board of Appeals.
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