Unfortunately, it may come to this.
If you find yourself faced with attending a grievance hearing to plead your case, don't let yourself get overwhelmed. Chances are if you've gotten this far, most of the background information and support documents you'll need are already in-hand.
When you are informed of the meeting time and place, be sure to inquire regarding your time frame for submitting evidence to your file. Members of the grievance committee traditionally get a complete copy of your file about a week in advance of your hearing. This gives everyone involved a chance to familiarize themselves with the case.
If you haven't already, submit evidence from healthcare professionals to support your case.
Summary of Recommendations, American Cleft Palate-Craniofacial Association
May, 1993, Rev. 2009
You may also be asked to inform the committee in advance of any legal counsel that may represent you at the hearing, or any person that might accompany you, whether it be to testify or simply lend moral support.
In the actual hearing, you will most likely be afforded only a few minutes to present your argument. It is important to prepare, in advance, a very straight-forward rebuttal to the company's denial. Any hand-outs should be distributed to the panel upon entering the room, before the presentation of your case. Note that hand-out materials should not be a copy of your presentation; rather it should consist of further documentation in support of your position.
The grievance committee panel will consist of:
Health plan employees are in attendance to answer any administrative questions that may arise and are non-voting members of the panel.
These physicians are participants in the health plan network; however, their areas of expertise may or may not be related to the treatment of cleft/craniofacial conditions. They are voting members of the panel.
Health plan members are people just like you--they are customers of the plan. These voting members of the panel are appointed on a rotating basis throughout the year.
Support staff personnel will take minutes of the proceedings and will direct follow-up correspondence on the committee's decision. Support staff are non-voting attendees.
The moderator will introduce those attending the proceedings and will announce your case to the panel. This person will direct the flow of testimony and recognize participants who wish to testify and/or ask questions.
You will probably be directed to a waiting room upon your arrival to the facility, as cases are heard privately for confidentiality concerns. The staff member will summon you to the meeting room. Upon entering, plan to distribute any hand-out materials you have prepared. Be seated and wait for direction from the Moderator.
When your case is announced, members of the voting committee may or may not ask questions of you or company personnel even before your presentation. This time will not be counted against your allotted time for testimony. Again, you may only have three to five minutes total to present your case in total.
When the moderator prompts you, take a deep breath and read your prepared presentation material. It is much better to read your comments than to stumble over your words, especially if you're nervous. After all, you will only have a short time to make several key points.
If you have practiced extensively and really know your presentation inside and out, use the opportunity to make eye contact with the voting panel. Voice inflection is also key. (In your typed material, bold-face type will assist you in making changes in your speaking voice to make important points stand out in the presentation...you'll recognize when to make changes, even if you're nervous.)
At the completion of your presenation, the Moderator will ask the panel if anyone has questions for you. Don't be afraid to ask someone to repeat their question if you don't understand them, and don't hesitate to ask a panel member to clarify terms for you.
At the conclusion of the question-and-answer period, the Moderator will thank you and a staff member will escort you from the room. Outside, that person may inform you of when you can expect an answer from the committee; however, check your Evidence of Coverage for mandated timelines.
No, they won't vote while you're there. They will deliberate and further review your file. They may vote that day, or ask for further information and postpone the vote until their next meeting. The company will inform you if the vote is delayed.
So for now, it is time to wait...
If you require further assistance, feel free to e-mail me. Likewise, if you can add information in the form of appeal letters, links to website information, anything to help others in this situation, please contact cleftAdvocate.