MedCom Care Management wants you to be satisfied with the services you are provided so we have a process to respond to your concerns and complaints. Additionally, the health plan has an appeal process to request review of coverage decisions.

Gilsbar’s Customer Contact Center

For questions about coverage, start by calling Gilsbar’s Customer Contact Center at the number on your ID card. A representative will try to answer your coverage questions, excluding requests concerning medical necessity review decisions.

Who may file an appeal?

A patient, or a person authorized to act on their behalf, has the right to request an appeal if they do not agree with MedCom’s decision about the non-certification of treatment, procedures, or services based on medical necessity or determination of experimental or investigational. If the person acting on behalf of the patient is not their legal guardian, an “Authorized Representative Designation” form may be requested by contacting MedCom at 1-800-643-4416.

How to appeal

The specific appeal process that applies to you is determined by the type of benefits plan chosen and follows state and/or federal rules that apply to that type of benefits plan.

To appeal a claim for medical necessity, a patient may do one of the following:

• Mail a written appeal, or deliver the appeal in person, to:
          MedCom Care Management, Inc.
          P.O. Box 1751
          2100 Covington Centre
          Covington, LA 70434, or
  
• Fax the appeal to the MedCom Medical Management Department at 1-985-898-1505, or
• In the case of an urgent claim, the patient or their treating provider may contact the MedCom Medical Management Department @ 1-800-643-4416

The appeal request should include the name of the employee, the employee’s personal identification number (PID), the group name or identification number, all facts and theories supporting the claim for benefits, a statement in clear and concise terms of the reason(s) for disagreement with the handling of the claim and any material or information which indicates the patient is entitled to benefits under the plan.

Decisions will be based upon the health benefit plan and requests will be reviewed by someone who was not involved in the initial decision. If the situation involves urgent care, the review and response will be expedited.

Complaint Process

To express dissatisfaction regarding MedCom’s products or services, you may do one of the following:

• Call the MedCom Medical Management Department @ 1-800-643-4416;
• Mail a written complaint, or deliver the complaint in person, to:
          MedCom Care Management, Inc.
          P.O. Box 1751
          2100 Covington Centre
          Covington, LA 70434; or
• Complete MedCom's Customer Satisfaction Survey