Understanding the CMS Star Ratings - Health Plan Customer Service HD5
Does the plan do a good job handling members’ appeals and processing new enrollment requests? This category shows how each plan performs in customer service areas. For example, it shows how quickly and how well the plan handles appeals made by members.This category is based on three (3) sub-categories:
The health plan customer service data comes from multiple sources: The information about appeals comes from an independent reviewer (also known as the Independent Review Entity or [IRE]). This organization evaluates the health plan’s appeals decisions. This information is based on cases processed by the independent reviewer.
Additional data source information for each sub-category is outlined below.
Health Plan Makes Timely Decisions about Appeals
Percent of plan members who got a timely response when they made an appeal request to the health plan about a decision to refuse payment or coverage.Data Source:
The information about appeals comes from an independent reviewer (also known as the Independent Review Entity or (IRE). This organization evaluates the health plan’s appeals decisions. This information is based on cases processed by the independent reviewer.
Fairness of Drug Plan’s Appeal Decisions
Fairness of the health plan’s appeal decisions, based on an Independent Reviewer. This measure/rating shows how often an Independent Reviewer thought the health plan’s decision to deny an appeal was fair. This includes appeals made by plan members and out-of-network providers. (This rating is not based on how often the plan denies appeals, but rather how fair the plan is when they do deny an appeal.)Data Source:
The information about appeals comes from an independent reviewer (also known as the Independent Review Entity or (IRE). This organization evaluates the health plan’s appeals decisions. This information is based on cases processed by the independent reviewer.
Call Center — Foreign Language Interpreter and TTY Availability
Availability of TTY services and foreign language interpretation when prospective members call the health plan. Percent of plan members who got a vaccine (flu shot) prior to flu season.Data Source:
Percent of the time that the TTY services and foreign language interpretation were available when needed by prospective members who called the health plan’s prospective enrollee customer service phone number.