Grievances and Appeals - Hospital and Medical Care

If you have a complaint about the coverage or payment of hospital or medical care that you receive, you have the right to file a complaint. Appeals and grievances are two different types of complaints you can make.

Grievances are complaints that don't involve coverage or payment for health care services. Rather, grievances involve how you are treated or what you experience in seeking health care services. Some examples are:

• You do not receive a decision about an organization determination on a timely basis;
• You believe our notices and other written materials are hard to understand;
• The cleanliness or conditions of your doctor's office, clinic, network pharmacy, or hospital are not satisfactory.

To file a grievance, you may write DaVita VillageHealth, 945 Lakeview Drive, Ste. 110, Vernon Hills, IL 60061 or call Customer Service 1-866-838-1962, TTY users dial 711, 8:00 a.m. to 8:00 p.m., 7 days a week.

If you call us, we will try to resolve your complaint immediately over the phone. If we cannot resolve your complaint during the call or you send us your complaint in writing, we will resolve your complaint as quickly as your health status requires but not later 30 days after your complaint is received.

Appeals involve a complaint about coverage or payment disputes in each of the following situations:

• Complaints about what benefit or service we will approve or what we will pay for.
• Complaints if you think you are asked to leave the hospital too soon.
• Complaints if you think your skilled nursing facility (SNF), home health agency (HHA) or comprehensive outpatient rehabilitation facility (CORF) services are ending too soon.

The first step in the appeal process is a medical care decision called an "organization determination." You, your physician, or your appointed representative may request an organization determination, either standard or expedited, by contacting DaVita VillageHealth and providing the information orally or in writing.

• Standard determinations are processed within 14 days.
• Expedited determinations are those where the need for an answer is time sensitive and a delay of 14 days might jeopardize your health. Expedited determinations are made in 72 hours.

An organization determination is our initial decision about whether we will provide the medical care or service you request, or pay for a service you have received.

If our initial decision is to deny your request, you may appeal the decision by going to Appeal Level 1 (see below). You may also appeal if we fail to make a timely initial decision on your request.

An Appeal Level 1 may be initiated if we deny any part of your request for a service or payment of a service. This is called an "appeal" or a "request for reconsideration." An appeal must be filed within 60 days of receiving a denial from DaVita VillageHealth.

In all, there are five appeal levels for hospital and medical care.

For more information on Grievance and Appeals for Hospital and Medical Care, please refer to Sections [8 and 9] of the Evidence of Coverage. Click here to view or download the Evidence of Coverage booklet.