Administrative Policies and Procedures

• Adding New Members to Gateway
• When You Move
• Other Insurance
• Claims-What Do I Do With a Bill?
• Changes in Benefits or Services
• Changing Health Plans
• When You Stop Being a Gateway Member
• Involuntary Disenrollment
• Rights and Responsibilities
  • Member Rights
  • Member Responsibilities
• COMPLAINTS
  • What is a complaint?
  • What should I do if I have a complaint?
  • First Level Complaint
  • What if I don't like Gateway’s decision?
  • Second Level Complaint
  • What happens after I file a second level complaint?
  • External Complaint Review
• GRIEVANCES
  • What is a grievance?
  • What should I do if I have a grievance?
  • What if I don't like Gateway’s decision?
  • Second Level Grievance
  • What can I do if I still don't like Gateway’s decision?
  • External Grievance Review
  • What can I do if my health is at immediate risk?
• Persons with Disabilities
• DEPARTMENT OF PUBLIC WELFARE FAIR HEARINGS
  • What happens after I ask for a fair hearing?
  • What can I do if my health is at immediate risk?
• Advance Directives
• HealthChoices Clinical Sentinel Hotline
• Suggestions for Changes
• Fraud and Abuse
• New Technology: Is it Covered?
• Other Information
• Eligibility

When you have a new baby or add a new member to your family, you should call Gateway Health Plan^® Member Services at 1-800-392-1147. A newborn will automatically be added to the mother’s health plan at the time of birth. It is also important to let your caseworker at the County Assistance Office know. If you don’t tell Gateway and your caseworker, your new family member’s Gateway Health Plan^® insurance may be delayed.

If you move, it is very important to tell your caseworker at the County Assistance Office. Gateway can only update your address and phone number after your caseworker updates your Department of Public Welfare file. Your new address and phone number are needed so that Gateway can send you information about your health plan. If you move out of the counties that Gateway services, you cannot keep your Gateway coverage. Call Member Services at 1-800-392-1147 to let Gateway know you moved.

You or one of your family members might have other types of insurance. Call the Member Services Department at 1-800-392-1147 if you or any member of your family is covered by Gateway and another insurance plan. Your caseworker at the County Assistance office also needs to know this information. If you have health, dental or vision insurance through another insurance company, you must use that insurance coverage first as a primary insurance. Gateway coverage is always the last payor to another insurance.

Pennsylvania Medical Assistance providers cannot charge you for services, co-pays or balances that are covered under your Gateway plan. If you get a bill from your doctor or the hospital by mistake, do not pay the bill. Please call Member Services at 1-800-392-1147, and a representative will help you with the bill.

Gateway Health Plan^® will let you know if there are changes in your benefits or the way you receive your services. An example of a change would be if your Primary Care Doctor or specialist is no longer part of Gateway’s list of participating doctors, called the “network”.  Member Services will call you or send a letter to give you a chance to pick a new doctor, so there will not be a problem for you to get the care you need.

If you would like to enroll with Gateway Health Plan^® or change your health plan from Gateway to another plan at any time:

If you live in one of the following counties, call the HealthChoices Hotline at 1-800-440-3989:

• Adams
• Allegheny
• Armstrong
• Beaver
• Berks
• Butler
• Cumberland
• Dauphin
• Fayette
• Greene
• Indiana
• Lancaster
• Lawrence
• Lebanon
• Lehigh
• Northampton
• Perry
• Washington
• Westmoreland
• York

If you live in any other county, call Enrollment Services at 1-800-485-5998.

The Independent Enrollment Assistance Program (IEAP) contractor is responsible for enrollment activities. The IEAP contractor employs trained, professional staff called Enrollment Specialists (ES). The ES's primary responsibility is to enroll MA consumers into the plan that best meets their needs. The ES assists consumers by providing objective information so they can choose a physical health plan for their medical needs and a PCP to manage their care.

Other responsibilities of the IEAP contractor include, but are not limited, to the following:

• Provide education and information to MA consumers to enable them to make informed choices of a physical health plan.
• Enroll MA consumers in the physical health plan of their choice
• Assist with the selection of a PCP
• Provide information about Behavioral Health Services and how to access those services

If you are hearing impaired and use a TTY/TDD (Telecommunication Device for the Deaf) service, you can call toll-free number, 1-800-618-4225 to enroll with Gateway or change your health plan from Gateway to another plan.

You will stay a member of Gateway Health Plan^® unless:

• You want to change health plans.
• You move from a HealthChoices to a non-HealthChoices county.
• You move outside of Gateway’s service area.
• The Pennsylvania Department of Public Welfare closes your case.

An “involuntary disenrollment” is when your Gateway membership ends without you asking for the change. Your Gateway membership will end if your case is “closed” by the Pennsylvania Department of Public Welfare.

If your case is “closed” for less than 6 months, and then opens up again, you will automatically be put back on Gateway Health Plan^®.

If your case is “closed” for more than 6 months, and then opens up again, and you live in the following HealthChoices counties, the Pennsylvania Department of Public Welfare will not put you back on Gateway Health Plan^® automatically.

If you want to become a Gateway Health Plan^® member again, you must call 1-800-440-3989 for your county that is listed below:

• Adams
• Allegheny
• Armstrong
• Beaver
• Berks
• Butler
• Cumberland
• Dauphin
• Fayette
• Greene
• Indiana
• Lancaster
• Lawrence
• Lebanon
• Lehigh
• Northampton
• Perry
• Washington
• Westmoreland
• York

If you do not call the HealthChoices Hotline to choose a plan, the Pennsylvania Department of Public Welfare will automatically choose a plan for you.

If you live in a county that is not listed above, and your case is “closed” for more than 6 months, you must call Enrollment Services at 1-800-485-5998 to get Gateway again.

It will take 4-6 weeks for your new membership to start.

There are some other reasons why Gateway membership must be ended. The Pennsylvania Department of Public Welfare sets up the reasons, and all plans like Gateway must follow them. If you live in one of the HealthChoices counties listed above, the reasons are:

• The Pennsylvania Department of Public Welfare closes your case. The Pennsylvania Department of Public Welfare will let you know if you are no longer eligible.
• You move outside the Gateway Health Plan’s service area. You must call Member Services at 1-800-392-1147 and tell Gateway about your move. You should also cut up your Gateway card.
• You move from a HealthChoices county listed above to another (voluntary) county within Gateway Health Plan’s network. You must call Enrollment Services at 1-800-485-5998 to get Gateway again.
• The agreement between the Pennsylvania Department of Public Welfare and Gateway Health Plan^® ends.

If you live in a county that is not listed above, there are a few more reasons why your membership must be ended. They are:

• When Gateway Health Plan^® feels that you and your doctor have not developed a good doctor-patient relationship. You will be given at least (15) fifteen days written notice when your Gateway coverage will end.
•   When Gateway Health Plan^® feels that you have failed to take the advice of Gateway doctors. You will be given at least (15) fifteen days written notice when your Gateway coverage will end.
• You break the rules of Gateway Health Plan^® membership. You will be told in writing when and why your coverage will end. If you have an “involuntary disenrollment”, you have the right to file a complaint through the Gateway Health Plan^® complaint procedure.

Rights and Responsibilities

Member Rights

As a Gateway Member, you have the right to:

1. Get information about Gateway, the services Gateway provides, doctors and other health care providers giving you care, and your rights and responsibilities as a Gateway member.
2. Be treated with respect and recognition of dignity and right for privacy when receiving health care.
3. Work with your doctor or other health care providers in making decisions about your health care and to express preferences about future treatment decisions.
4. Openly discuss without any limitations by Gateway appropriate or medically necessary treatment choice for your condition with a doctor or other health care provider, including treatment options, risks of treatment, alternative therapies, and consultations or tests that may be self administered, regardless of the cost or if it is a benefit.
5. Receive your medical and nursing care without regard to race, color, religion, sex, age, disability, national origin, or without regard to whether you have an advance directive.
6. Pick your own doctor from Gateway’s network of doctors.
7. Refuse care from certain doctors.
8. File a complaint or grievance about Gateway or the care it provides.
9. Make recommendations regarding Gateway’s members’ rights and responsibilities policies.
10. Request a fair hearing from the Department of Public Welfare.
11. Prepare a Living Will and/or an Advance Directive.
12. See, or have your medical record copied, within Federal and State laws, and to request that your medical record be changed or corrected within Federal laws.
13. Have your medical records kept private and confidential.

As a Gateway Health Plan^® member, you have a responsibility to:

1. Give information to your doctor, other health care provider, or Gateway so they can provide care to you.
2. Follow the instructions and treatment plans that you agreed on with your doctor or other health care provider.
3. Provide consent to health care providers and Gateway to help them manage your care, to improve your health or for research.
4. Understand your health problems. As much as you can, take part in making a plan for treatment goals with your doctor or other health care providers.
5. See the doctor you picked on a regular basis.
6. Treat the people giving you medical care with the same respect and kindness you expect for yourself.

If a provider or Gateway Health Plan^® does something that you are unhappy about or do not agree with, you can tell Gateway Health Plan^® or the Department of Public Welfare that you are unhappy or you disagree with what the provider or Gateway Health Plan^® has done.  This section describes what you can do and what will happen.

You may call Gateway Health Plan’s toll-free Member Services telephone number at 1-800-392-1147 if you need help or have questions about complaints, grievances or fair hearings, you can contact your local legal aid office or call the Pennsylvania Health Law Project at 1-800-274-3258. If you need help getting the local legal aid telephone number, please call Gateway’s toll-free Member Services telephone number listed above.

A complaint is when you tell Gateway Health Plan^® you are unhappy with Gateway or your provider or do not agree with a decision by Gateway.

Some things you may file a complaint about:

• You are unhappy with the care you are getting.
• You cannot get the service or item you want because it is not a covered service or item.
• You have not gotten services that Gateway approved.

What should I do if I have a complaint?

First Level Complaint

To file a complaint, you can:

Call Gateway Health Plan^® at 1-800-392-1147 to tell your complaint, or write down your complaint and send it to Gateway at: 

Gateway Health Plan
US Steel Tower Floor 41
600 Grant St.
Pittsburgh, PA 15219-2704

or  your provider can file a complaint for you if you give the provider your consent in writing to do so.

NOTE: If your provider files a complaint for you, you cannot file a separate complaint on your own.

This is called a first level complaint.

When should I file a first level complaint?

1. You must file a complaint within 45 days of getting a letter telling you that:
   • Gateway Health Plan^® has decided that you cannot get a service or item you want because it is not a covered service or item
   • Gateway Health Plan^® will not pay a provider for a service or item you got.
   • Gateway Health Plan^® did not decide a complaint or grievance that you had reported within 30 days.
2. You must file a complaint within 45 days of the date you should have gotten a service or item if you did not get a service or item.
3. You may file all other complaints at any time.

What happens after I file a first level complaint?

After you file your complaint, you will get a letter from Gateway Health Plan^® telling you that Gateway has received your complaint, and about the first level complaint review process.

You may ask Gateway Health Plan^® to see any information Gateway has about your complaint.  You may also send information that may help with your complaint to Gateway.

You may attend the complaint review if you want to.  You may come to Gateway Health Plan’s offices or be included by phone or by videoconference. If you decide that you do not want to attend the complaint review, it will not affect Gateway’s decision.

A committee of one or more Gateway Health Plan^® staff who has not been involved in the issue will review your complaint and make a decision within 30 days after Gateway receives your complaint.

A decision letter will be mailed to you within 5 business days after the decision is made.  This letter will tell you all the reason(s) for the decision and what you can do if you don’t like the decision.

What to do to continue getting services during the First Level Complaint:

If you have been receiving services or items that are being reduced, changed or stopped and you file a complaint that is hand-delivered or postmarked within 10 days of the date on the letter (notice) telling you that the services or items you have been receiving are not covered services or items for you, the service or items will continue until a decision is made.

What if I don’t like Gateway’s decision?

Second Level Complaint

If you do not agree with the first level complaint decision, you may file a second level complaint with Gateway.

When should I file a second level complaint?

You must file your second level complaint within 45 days of the date you receive the first level complaint decision letter.  Use the same address or phone number you used to file your first level complaint.

You will receive a letter telling you that Gateway has received your complaint, and telling you about the second level complaint review process.

You may ask Gateway to see any information Gateway Health Plan^® has about your complaint.  You may also send information that may help with your complaint to Gateway.

You may attend the complaint review if you want to.  You may come to Gateway Health Plan’s offices or be included by phone or by videoconference. If you decide that you do not want to attend the complaint review, it will not affect Gateway’s decision.

A committee made up of three or more people, who have not been involved in the issue, will review your complaint and make a decision. At least one third of the second level review committee may not be employees of the plan or of a related subsidiary or affiliate. Your complaint will be decided within 45 days after Gateway receives your complaint.

A decision letter will be mailed to you within 5 business days after the decision is made.  This letter will tell you all the reason(s) for the decision and what you can do if you don’t like the decision.

What to do to continue getting services during the Second Level Complaint:

If you have been receiving services or items that are being reduced, changed or stopped because they are not covered services or items for you and you file a second level complaint that is hand-delivered or postmarked within 10 days of the date on the first level complaint decision letter, the services or items will continue until a decision is made.

If you do not agree with Gateway’s second level complaint decision, you may ask for an external review by either the Department of Health or the Insurance Department.  The Department of Health handles complaints that involve the way a provider gives care or services.  The Insurance Department reviews complaints that involve Gateway’s policies and procedures.

You must ask for an external review within 15 days of the date you received the second level complaint decision letter.  If you ask, the Department of Health will help you put your complaint in writing.

You must send your request for external review in writing to either:

Department of Health
Bureau of Managed Care
Attention: Complaint Appeals
P.O. Box 90
Harrisburg, PA 17108-0090
Phone: 1-888-466-2787

Or

Pennsylvania Insurance Department
Bureau of Consumer Services
1321 Strawberry Square
Harrisburg, PA 17120
Phone: 1-877-881-6388

If you send your request for external review to the wrong department, it will be sent to the correct department.

The Department of Health or the Insurance Department will get your file from Gateway.  You may also send Gateway any other information that may help with the external review of your complaint.

You may be represented by an attorney or another person during the external review.

A decision letter will be sent to you after the decision is made.  This letter will tell you all the reason(s) for the decision and what you can do if you don’t like the decision.

What to do to continue getting services during the External Complaint Review:

If you have been receiving services or items that are being reduced, changed or stopped because they are not covered services or items for you and you file a request for an external complaint review that is hand-delivered or postmarked within 10 days of the date on the second level complaint decision letter, the services or items will continue until a decision is made.

GRIEVANCES

What is a grievance?

When Gateway Health Plan^® denies, decreases, or approves a service or item different than the service or item you requested because it is not medically necessary, you will get a letter (notice) telling you Gateway’s decision.

A grievance is when you tell Gateway you disagree with the decision.

First Level Grievance

To file a grievance, you can:

Call Gateway at 1-800-392-1147 to file your grievance, or

Write down your grievance and send it to Gateway at

Gateway Health Plan^®
US Steel Tower Floor 41
600 Grant St.
Pittsburgh, PA 15219-2704

or  your provider can file a grievance for you if you give the provider your consent in writing to do so.

NOTE: If your provider files a grievance for you, you cannot file a separate grievance on your own.

When should I file a first level grievance?

You have 45 days from the date you receive the letter (notice) that tells you about the denial, decrease, or approval of a different service or item, to file your grievance.

What happens after I file a first level grievance?

After you file your grievance, you will get a letter telling you that Gateway has received your grievance, and about the first level grievance review process.

You may ask Gateway to see any information Gateway Health Plan^® has about your grievance.  You may also send information that may help with your grievance to Gateway.

You may attend the grievance review if you want to. You may come to Gateway’s offices or be included by phone or by videoconference.  If you decide that you do not want to attend the grievance review, it will not affect Gateway’s decision.

A committee of one or more Gateway Health Plan^® staff, including a licensed doctor or dentist, who have not been involved in the issue you filed your grievance about, will review your grievance and make a decision.  Your grievance will be decided no later than 30 days after Gateway receives your grievance.

A decision letter will be mailed to you within 5 business days after the decision is made.  This letter will tell you all the reason(s) for the decision and what you can do if you don’t like the decision.

What to do to continue getting services during the First Level Grievance review:

If you have been receiving services or items that are being reduced, changed or stopped, and you file a grievance that is hand-delivered or postmarked within 10 days of the date on the letter (notice) telling you that the services or items you have been receiving are being reduced, changed or stopped, the services or items will continue until a decision is made.

What if I don’t like Gateway’s decision?

Second Level Grievance

If you do not agree with the first level grievance decision, you may file a second level grievance with Gateway.

You must file your second level grievance within 45 days of the date you receive the first level grievance decision letter.  Use the same address or phone number you used to file your first level grievance.

What happens after I file a second level grievance?

You will receive a letter telling you that Gateway has received your grievance, and telling you about the second level grievance review process.

You may ask Gateway to see any information Gateway Health Plan^® has about your grievance.  You may also send information that may help with your grievance to Gateway.

You may attend the grievance review if you want to.  You may come to Gateway’s offices or be included by phone or by videoconference.  If you decide that you do not want to attend the grievance review, it will not affect Gateway’s decision.

A committee of three or more people including a doctor or dentist who have not been involved in the issue you filed your grievance about, will review your grievance and make a decision. At least one third of the second level review committee may not be employees of the plan or of a related subsidiary or affiliate. Your grievance will be decided no later than 45 days after Gateway receives your grievance.

A decision letter will be mailed to you within 5 business days after the decision is made. This letter will tell you all the reason(s) for the decision and what you can do if you don’t like the decision.

What to do to continue getting services during the Second Level Grievance review:

If you have been receiving services or items that are being reduced, changed or stopped and you file a second level grievance that is hand-delivered or postmarked within 10 days of the date on the first level grievance decision letter, the services or items will continue until a decision is made.

What can I do if I still don’t like Gateway’s decision?

External Grievance Review

If you do not agree with Gateway’s second level grievance decision, you may ask for an external grievance review.

You must call or send a letter to Gateway asking for an external grievance review within 15 days of the date you received the second level grievance decision letter.  Use the same address and phone number you used to file your first level grievance.  Gateway will then send your request to the Department of Health.

The Department of Health will notify you of the external grievance reviewer’s name, address and phone number.  You will also be given information about the external review process.

Gateway will send your grievance file to the reviewer.  You may provide additional information that may help with the external review of your grievance, to the reviewer, within 15 days of filing the request for an external grievance review.

You will receive a decision letter within 60 days of the date you asked for an external grievance review.  This letter will tell you all the reason(s) for the decision and what you can do if you don’t like the decision.

What to do to continue getting services during the External Grievance Review:

If you have been receiving services or items that are being reduced, changed or stopped and you request an external grievance review that is hand-delivered or postmarked within 10 days of the date on the second level grievance decision letter, the services or items will continue until a decision is made.

Expedited Complaints and Grievances

If your doctor or dentist believes that the usual timeframes for deciding your complaint or grievance will harm your health, you or your doctor or dentist can call Gateway Health Plan^® at 1-800-392-1147 and ask that your complaint or grievance be decided faster.  You will need to have a letter from your doctor or dentist faxed to (412-255-4503) explaining how the usual timeframe for deciding your complaint or grievance will harm your health.

If your doctor or dentist does not fax Gateway this letter, your complaint or grievance will be decided within the usual timeframes.

Expedited Complaint

>The expedited complaint will be decided by a licensed doctor or dentist, who has not been involved in the issue you filed your complaint about.

Gateway Health Plan^® will call you within 3 business days of when Gateway receives your request for an expedited (faster) complaint review with Gateway’s decision.  You will also receive a letter telling you the reason(s) for the decision and how to file a second level complaint, if you don’t like the decision. 

An expedited complaint decision may not be requested after a first level complaint decision has been made on the same issue.

Expedited Grievance and Expedited External Grievance

A committee of three or more people, including a licensed doctor or dentist, will review your grievance. The licensed doctor or dentist will decide your expedited grievance with help from the other people on the committee.  No one on the committee will have been involved in the issue you filed your grievance about.

Gateway Health Plan^® will call you within 48 hours from receiving the provider’s certification or 3 business days of when Gateway receives your request for an expedited (faster) grievance review with the decision.  You will also receive a letter telling you the reason for the decision and, that you can ask for an expedited external grievance review, if you don’t like the decision.

If you want to ask for an expedited external grievance review by the Department of Health, you must call Gateway Health Plan^® at 1-800-392-1147 within 2 business days from the date you get the expedited grievance decision letter.  Gateway will send your request to the Department of Health within 24 hours after receiving it.

An expedited grievance decision may not be requested after a second level grievance decision has been made on the same issue.

What kind of help can I have with the complaint, grievance processes?

If you need help filing your complaint or grievance, a staff member of Gateway Health Plan^® will help you.  This person can also represent you during the complaint or grievance process.  You do not have to pay for the help of a staff member.  This staff member will not have been involved in any decision about your complaint or grievance.

You may also have a family member, friend, lawyer or other person help you file your complaint or grievance.  This person can also help you if you decide you want to appear at the complaint or grievance review.  For legal assistance you can contact your local legal aid office by calling 1-800-440-3989. If you need help getting the local legal aid telephone number, please call Gateway’s toll-free Member Services telephone number at 1-800-392-1147.

At any time during the complaint or grievance process, you can have someone you know represent you or act on your behalf.  If you decide to have someone represent or act for you, tell Gateway Health Plan^®, in writing, the name of that person and how we can reach him or her.

You or the person you choose to represent you may ask Gateway Health Plan^® to see any information Gateway has about your complaint or grievance.

If you ask for language interpreter services, Gateway Health Plan^® will provide the services at no cost to you.

Gateway Health Plan^® will provide persons with disabilities with the following help in presenting complaints or grievances at no cost, if needed.  This help includes:

• providing sign language interpreters;
• providing information submitted by Gateway at the complaint or grievance review in an alternative format. The alternative format version will be given to you before the review;
• providing someone to help copy and present             information.

DEPARTMENT OF PUBLIC WELFARE FAIR HEARINGS

In some cases you can ask the Department of Public Welfare to hold a hearing because you are unhappy or do not agree with something Gateway did or did not do.  These hearings are called “fair hearings”.  You can ask for a fair hearing at the same time you file a complaint or grievance or you can ask for a fair hearing after Gateway decides your first or second level complaint or grievance.

What kind of things can I request a fair hearing about and when do I have to ask for my fair hearing?

How do I ask for a fair hearing?

You must ask for a fair hearing in writing and send it to:
Department of Public Welfare
Office of Medical Assistance Programs –
HealthChoices Program
Complaint, Grievance and Fair hearings
PO Box 2675
Harrisburg, PA 17105-2675

Your request for a fair hearing should include the following information:

• member name;
• member social security number and date of birth;
• a telephone number where you can be reached during the day;
• if you want to have the fair hearing in person or by telephone;
• and any letter you may have received about the issue you are requesting your fair hearing for.

You will get a letter from the Department of Public Welfare’s Bureau of Hearings and Appeals telling you where the hearing will be held and the date and time for the hearing.  You will receive this letter at least 10 days before the date of the hearing.

You may come to where the fair hearing will be held or be included by phone.  A family member, friend, lawyer or other person may help you during the fair hearing.

Gateway will also participate in the fair hearing to explain why the decision was made or explain what happened.

If you ask, Gateway must give you (at no cost to you) any records, reports and other information Gateway has that is relevant to what you requested your fair hearing about.

When will the fair hearing be decided?

If you ask for a fair hearing after a first level complaint or grievance decision, the fair hearing will be decided no more than 60 days after the Department of Public Welfare gets your request.

If you ask for a fair hearing and did not file a first level complaint or grievance, or if you ask for a fair hearing after a second level complaint or grievance decision, the fair hearing will be decided within 90 days from when the Department of Public Welfare gets your request.

If your fair hearing is not decided within 90 days from the date that the Department of Welfare receives your request, you may be able to get interim assistance until the decision is made.

What to do to continue getting services during the Fair Hearing:

If you have been receiving services or items that are being reduced, changed or stopped and your request for  fair hearing is hand-delivered or postmarked within 10 days of the date on letter (notice) telling you that Gateway has reduced, changed or denied your services or items or telling you Gateway decision about your first or second level complaint or grievance, your services or items will continue until a decision is made.

Expedited Fair Hearing

If your doctor or dentist believes that using the usual timeframes to decide your fair hearing will harm your health, you or your doctor or dentist can call the Department of Public Welfare at 1-800-798-2339 and ask that your fair hearing be decided faster.  This is called an expedited fair hearing.  You will need to have a letter from your doctor or dentist faxed to 717-772-6328 explaining why using the usual timeframes to decide your fair hearing will harm your health.  If your doctor or dentist does not send a written statement, your doctor or dentist may testify at the fair hearing to explain why using the usual timeframes to decide your fair hearing will harm your health.

The Bureau of Hearings and Appeals will contact you to schedule the expedited fair hearing.  The expedited fair hearing will be held by telephone within 3 business days after you ask for the fair hearing. 

If your doctor does not send a written statement and does not testify at the fair hearing, the fair hearing decision will not be expedited.  Another hearing will be scheduled, and the time frame for the fair hearing decision will be based on the date you asked for the fair hearing. 

If your doctor sent a written statement or testifies at the hearing, the decision will be made within 3 business days after your fair hearing was held.

If you are admitted as a patient to a hospital, you will be asked if you have any Advance Directives. An Advance Directive is any instructions you give about your medical care before medical services are done. Advance Directives are only followed in the future when you are unable to say what medical care you want.

There are two kinds of Advance Directives. One is called a “living will” and the other is called a “durable power of attorney.”

A “living will” spells out what kind of life-sustaining care you want to get in a terminal condition or permanent state of coma.

A “durable power of attorney” for health care lists someone who can make health care decisions for you. This would be if you could not make and tell people your decisions.

An Advance Directive might be used when a person is in a coma and cannot tell the doctor what type of care he or she wants.

It is your legal right to make Advance Directives about your medical care. It is also something you may want to talk to your doctor about.

Gateway will send you information about the current Pennsylvania law regarding the Patient Self Determination Act. This is the law that covers Advance Directives. Call Gateway’s Member Services at 1-800-392-1147 for a copy.

Gateway will notify you, by letter, of any changes in Pennsylvania law about Advance Directives within 90 days of the change.

If you believe that a doctor or hospital has not followed the instructions of your advance directive you may contact Gateway to find out how to file a complaint with Gateway  or with the Department of Health.

The Medical Director for the Office of Medical Assistance Programs at the Department of Public Welfare (DPW) set up the  Clinical Sentinel Hotline (CSH). The CSH was developed to ensure that the HealthChoices managed care medical plans and behavioral health plans honor your right to have your request for medically necessary care and services responded to in a timely manner. The CSH helps all Medical Assistance recipients who are enrolled in the HealthChoices Program

If you live in one of the following counties, you may call the Clinical Sentinel Hotline at the Department of Public Welfare at 1-800-426-2090:

Nurses who work for DPW answer the CSH. If you or your medical providers have requested medical care or services, and your managed care medical plan or behavioral health plan has not responded in time to meet your needs, call the CSH. The CSH will work along with the medical plan or behavioral health plan responds to your request soon enough to meet your needs. You can also call the CSH if your medical plan

or behavioral health plan has denied you medically necessary care or services and won’t accept your request to file a grievance.

The CSH operates Monday through Friday between 9am and 5pm. Call 1-800-426-2090.

The CSH cannot provide or approve urgent or emergency care. If you believe you have an urgent or emergency medical situation, you should seek the care you need with your PCP or local hospital.

If you have questions about your care or Gateway services, and you live outside of the above listed counties, call Gateway Health Plan’s Member Services Department at 1-800-392-1147.

If you would like to suggest changes to any Gateway Health Plan^® Policies and Procedures, please call the Member Services Department at 1-800-392-1147.

If you think that someone is using your Gateway Health Plan^® identification (ID) card to get medical or

prescription drug benefits, call Gateway’s Fraud and Abuse Hotline at 412-255-4340. Your name will be kept private. If you are not in the 412 area code, call the Gateway Member Services Department at 1-800-392-1147 to report this activity.

You may also report this information to the Department of Public Welfare’s Medical Assistance Provider Compliance Hotline at 1-866-DPW-TIPS (1-800-379-8477).  You can report any provider (for example a doctor, dentist, therapist, or hospital) for suspected fraud or abuse for services provided to anyone with an Access card.

Some common examples of fraud and abuse are:

• Billing or charging you for services that your health plan covers
• Offering you gifts or money to receive treatment or services for your Access number
• Giving you treatment or services that you don’t need
• Physical, mental, or sexual abuse by medical staff

You can call the Hotline and speak to someone Monday through Friday 8:30AM to 3:30PM.  You may leave a voice mail message at other times.  If you don’t speak English, an interpreter will be made available.  If you are hearing impaired, you can call the hotline using your TTY device.

You do not have to give your name and if you do give your name, the provider will not be told you called.

You can also report suspected fraud and abuse by using the website:  http://www.dpw.state.pa.us/omap or email omaptips@state.pa.us.  This has been set up so you do not have to give your name also.

Recipient Restriction Program

Gateway Health Plan^® and the Department of Public Welfare have the right to restrict members to specific provider types when it has been determined that the member has abused his or her health care benefits.

The member may appeal the restriction by submitting to the Department of Public Welfare a written request for a Fair Hearing within 30 days from the date of the letter.

A request for a DPW Fair Hearing must be in writing, signed by the member and sent to:

Department of Public Welfare
Division of Program and Provider Compliance
Bureau of Program Integrity
Recipient Restriction Section
P.O. Box 2675
Harrisburg, Pennsylvania  17110

Requests by the member, pharmacy, or physician for a restriction change must be in the form of a written request that is sent to the Gateway Restriction Liaison. Once the request is received and reviewed, the person requesting the change will be notified of Gateway’s decision.

Gateway Health Plan^® evaluates new technology to decide if it should be included as a covered benefit. New technology means any skills, equipment or know-how of doing something better.

A committee of Gateway physicians evaluates information on new technology. If they recommend that a new technology be included in Gateway’s benefits package, the recommendation will be shared with Gateway’s Senior Management for more evaluation and approval. The committee may recommend that the new technology be approved on a case-by-case basis.

Gateway has pharmacists and physicians who look at new drugs and new uses for drugs four times a year. New drugs are added to the formulary list four times a year, and drugs are removed from the formulary list two times a year.

If you would like any information about Gateway Health Plan^® including who sits on the Board of Directors, what the education of your doctor is, or the way we plan to improve the care and services to our members through Gateway Health Plan’s Quality Improvement Program, call Member Services at 1-800-392-1147.

The Department of Public Welfare decides if you qualify for Medical Assistance. They also decide what health care benefits you get based on your level of assistance. You should call your caseworker if you have any questions about your Medical Assistance coverage of health care package.