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«Member Handbook UWV-MHB-0003-14 12.14 Dear Member: Welcome to UniCare Health Plan of West Virginia, Inc.! This is your member handbook. Here, you ...»

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How to get other services You can get help from a special program called Women, Infants and Children (WIC). The WIC program gives healthy food to pregnant women and mothers of young children. WIC also will tell you about foods that are good for you. If you have questions about WIC services, or wish to enroll in the WIC program, call your DHHR caseworker for information.

unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

UWV-MHB-0003-14 WV MHB ENG 12.14 Part 11 – Help with special services Help in other languages We provide free oral interpretation services in more than 140 languages. We want you to have

the right care, so we have:

 Staff members who can get you help in your language  24-hour telephone interpreters  Sign language and face-to-face interpreters  Providers who can get you help in your language If you need help in a language other than English during your medical visit, you can ask for an interpreter at no cost. Call us Monday through Friday, 8 a.m. to 5 p.m., and we will get someone who speaks your language.

You can call our 24-hour nurse help line if you need someone to interpret for you after regular office hours.

Help for members with hearing or speech loss If you have hearing or speech loss, you may call our toll-free TTY line from 8 a.m. to 5 p.m.

Monday through Friday, at 1-866-368-1634. To get the help you need between 5 p.m. and 8 a.m. and on weekends, call the West Virginia Relay Service at 1-800-982-8772 or their TTY line at 1-800-982-8771. After regular business hours, you can also call MedCall at 1-888-850-1108.

The MedCall TTY line is 1-800-368-4424.

We can provide this member handbook and other important plan materials in different ways.

This is so people that do not see well can still learn about their plan. Here are the ways we can

do this:

 Large print  A CD for listening to plan information  Braille  Audiotape Please call us to get these other formats, or for help reading this handbook.

Americans with Disabilities Act We meet the terms of the Americans with Disabilities Act (ADA) of 1990. This act protects you from unfair actions by your health plan because of a disability. Please call us if you feel you have not been treated the same as others because of a disability.

Please call us first at our Customer Care Center at 1-800-782-0095. Give us a chance to help you.

If you have a problem We want to help. If you do not agree with a decision we made, or if you have a problem with the care you received, you can file a complaint or a grievance with us.

Talk to your PCP first if you have questions or concerns about your care. If you still have questions or concerns, call us. We can help you. You will not be treated in a different way for filing a complaint. If you have questions about how we make medical decisions, call our Utilization Management office Monday through Friday, 8 a.m. and 5 p.m. The phone number is 1-866-655-7423.

Complaints A complaint is a way for you or someone you choose to tell us when you are not happy with something. You can write, call, fax or email us to let know about your complaint. We will take care of your complaint when we get it or send it to the right place for a final answer. You may choose not to be named when making a complaint.

If our CCC staff cannot resolve your complaint, we will send it right away to a Member Advocate for review. This is a person who is in charge of looking into and finding an answer to your complaint. We will make a ruling within one business day after the Member Advocate review.

We will let you know what we decide by phone or in writing.

Grievances You can file a grievance if you have a problem with the quality of the health care or administrative service you receive. A grievance does not deal with the denial of benefits for health care service. Those matters are handled as appeals (see Appeals below).

To file a grievance, you or someone you choose should state the problem in writing within one year from the date the problem happened. To do so, fill out a UniCare grievance form, or write unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

UWV-MHB-0003-14 WV MHB ENG 12.14 a letter telling us about the problem. You can find these forms at UniCare offices and provider offices. The grievance form is also available on our website.

Send your completed form or letter to:

Attn: Grievance and Appeals Department UniCare Health Plan of West Virginia, Inc.

P.O. Box 91 Charleston, WV 25321-0091 If you cannot mail the form or letter, you or someone you choose can call us and tell us about your problem. You may also receive information about the grievance process in a language other than English at no cost to you. Oral interpreter services are also available to you at no cost.

If you want to use this service, please call our CCC at 1-800-782-0095 (TTY 1-866-368-1634).

Here are the things you need to tell us as clearly as you can:

 Who is involved in the grievance  What happened  When it happened  Where it happened  Why you are not happy with the health care you received Attach any documents that will help us look into the problem. If you need us to, we will help you file your grievance.





We will send you a letter within five calendar days after we get your grievance. If we can, we will call you for issues that need to be taken care of right away. We will send you a written response within 24 hours. The letter will tell you about your right to meet face-to-face with staff at our CRC in Charleston.

Our goal is to solve your problem. We will ask the staff person who knows the most about your issue to review it.

 Quality of care issues (also called clinical quality issues) are looked into first by a Grievance and Appeals associate, who then decides who will complete the final review. A medical director reviews all medical-related grievances, decides how serious they are and gives recommendations on how to solve each problem.

 Administrative issues (also called quality of service issues) are reviewed by UniCare staff to solve your problem.

Appeals You may file an appeal if we don’t approve a service, if we take too long to approve it or if there is a change to your request for services. You or someone you choose can ask for an appeal. This

must be done in writing and sent to:

ATTN: Grievance and Appeals Department UniCare Health Plan of West Virginia, Inc.

P.O. Box 91 Charleston, WV 25321-0091 Fax: 1-866-387-2968 You also may file an appeal by calling our CCC at 1-800-782-0095 (TTY 1-866-368-1634). Written and signed appeals must be filed even after you requested this by phone. This is except in the case of an appeal that needs to be rushed through. You do not have to pay to file an appeal.

We will send you an acknowledgment letter within five business days. It will tell you that we got your appeal request. We will send you an appeal resolution letter within 45 days from the date the initial appeal was filed. You or someone you choose may extend the appeal for 14 calendar days. We also may extend the appeal for 14 calendar days if we need to find out more information about your request.

You may receive information about the appeals process in a language other than English at no cost to you. Oral interpreter services are also available to you at no cost. If you want to use this service, please call our CCC at 1-800-782-0095 (TTY 1-866-368-1634).

Your benefits may continue while your appeal is pending as long as you submit your appeal within 10 days after our mailing of the Notice of Action letter, or the intended effective date of the proposed action. You may have to pay for services you get while you wait for an answer about your appeal if the final decision is not the same as what you asked for.

Expedited appeal You may ask for an expedited (fast) appeal if we need to make a decision quickly based on your health status. We will process your request as quickly as we can, but we will not take more than 72 hours from the date we received your appeal. The 72-hour limit may be extended up to 14 days if you ask for it or we need more information to make the decision and the delay is in your interest. If we cannot make a decision within 72 hours, we will send you a letter that gives you the reason for the delay.

unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

UWV-MHB-0003-14 WV MHB ENG 12.14 Grievance and appeals for dental services Dental Grievances You can file a grievance if you have a problem with the quality of the dental care you receive.

To file a dental grievance, you or someone you choose should state the problem in writing within one year from the date the problem happened. To do so, fill out a grievance form, or write a letter telling Scion Dental about the problem. You can find these forms at provider offices. The grievance form is also available at http://sciondental.com. Send your completed

form or letter to:

Scion Dental of West Virginia — Appeals P.O. Box 1396 Milwaukee, WI 53201 If you cannot mail the form or letter, you or someone you choose can call Scion and tell them about your problem. You may call Scion at 1-888-983-4697 (TTY 1-800-508-6975). You also may receive information about the grievance process in a language other than English at no cost to you. Oral interpreter services are also available to you at no cost. If you want to use this service, please call the UniCare CCC at 1-800-782-0095 (TTY 1-866-368-1634). UniCare and Scion will work together with the interpreter.

Here are the things you need to tell us as clearly as you can:

 Who is involved in the grievance  What happened  When it happened  Where it happened  Why you are not happy with the dental care you received Attach any documents that will help us look into the problem. If you need help, Scion will help you file your grievance.

Scion will send you a letter within five calendar days after they get your grievance in the mail or by phone. Scion will call you for issues that need to be taken care of right away and send you a written response within three calendar days if your issue needs to be taken care of right away.

The letter will tell you about your right to meet face-to-face with staff at the CRC in Charleston.

UniCare can help you set up a face-to-face meeting. Call us at 1-800-782-0095 for assistance.

The goal is to solve your problem. Scion will ask the staff person who knows the most about

your issue to review it:

UWV-MHB-0003-14 WV MHB ENG 12.14 • Quality of care issues (also called clinical quality issues) are looked into first by a Grievance and Appeals associate, who then decides who will complete the final review.

• A dental director reviews all clinical quality issues, decides how serious they are and gives recommendations on how to solve each problem.

• Administrative issues (also called quality of service issues) are reviewed by a UniCare associate who consults with Scion to solve your problem.

Scion will send you a grievance resolution letter within 30 calendar days after they get your grievance. Scion can ask for 14 more days if they need to know more. Scion will send you a letter telling you why more time was needed. You may also ask for 14 more days if you need more time.

Dental appeals You may file an appeal if Scion doesn’t approve a service, if Scion takes too long to approve it or if there is a change to your request for services. You or someone you choose can ask for an

appeal. This must be done in writing and sent to:

Scion Dental of West Virginia — Appeals P.O. Box 1396 Milwaukee, WI 53201 You also may file an appeal by calling Scion at 1-888-983-4697 (TTY 1-800-508-6975). You do not have to pay to file an appeal.

Scion will send you an acknowledgment letter within five business days. It will tell you that Scion got your appeal request. Scion will send you an appeal resolution letter within 14 days from the date the initial appeal was filed. You, or someone you choose to help you or speak for you, may extend the appeal for 14 calendar days. Scion also may extend the appeal for 14 calendar days if Scion needs to find out more information about your request. You will get a letter from Scion if the appeal is extended.

You may receive information about the appeals process in a language other than English at no cost to you. Oral interpreter services are also available to you at no cost. If you want to use this service, please call the UniCare CCC at 1-800-782-0095 (TTY 1-866-368-1634).

Your benefits may continue while your appeal is pending as long as you submit your appeal within 10 days after Scion mails the Notice of Action letter, or the intended effective date of the proposed action. You may have to pay for services you get while you wait for an answer about your appeal if the final decision is not the same as what you asked for.

UWV-MHB-0003-14 WV MHB ENG 12.14 Expedited appeal You may ask for an expedited appeal if Scion needs to make a decision quickly based on your health status. Scion will process your request as quickly as they can, but Scion will not take more than three calendar days from the date it received your appeal. The 3-day limit may be extended up to 14 days if you ask for it or Scion needs more information to make the decision and the delay is in your interest. If Scion cannot make a decision within three calendar days, it will send you a letter that gives you the reason for the delay.

State fair hearing

You or someone you choose to represent you may ask for a state fair hearing if:

 We have denied, deferred or modified a service  If we have failed to give you timely service You have 90 calendar days from the date on the Notice of Action letter to ask for a state fair hearing. You must go through the UniCare Grievance and Appeals process before requesting a state fair hearing.



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