1st Level Formal Appeal. When an Informal Review is not resolved in a manner that is satisfactory to the Insured or when the Insured chooses not to file an Informal Review and the Insured wishes to pursue the matter further, the Insured must file a 1st
1st Level Formal Appeal. When an Informal Review is not resolved in a manner that is satisfactory to the Member or when the Member chooses not to file an Informal Review and the Member wishes to pursue the matter further, the Member must file a 1st Level Formal Appeal. The 1st Level Formal Appeal must be submitted orally or in writing to HPN’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Such 180 days will run concurrently with the 180 day time period applicable to an Informal Review as set forth herein. NOTE: 1st Level Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. The 1st Level Formal Appeal shall contain at least the following information: The Member’s name (or name of Member and Member’s Authorized Representative), address, and telephone number; The Member’s HPN membership number and Group name; and A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Member feels that the Adverse Benefit Determination was wrong. Additionally, the Member may submit any supporting medical records, Physician’s letters, or other information that explains why HPN should approve the Claim for Benefits. The Member can request the assistance of a Member Services Representative at any time during this process. The 1st Level Formal Appeals should be sent or faxed to the following: Health Plan of Nevada, Inc. Attn: Customer Response and Resolution Department XX Xxx 00000 Xxx Xxxxx, XX 00000 HPN will investigate the appeal. When the investigation is complete, the Member will be informed in writing of the resolution within thirty (30) days of receipt of the request for the 1st Level Formal Appeal. This period may be extended one (1) time by HPN for up to fifteen (15) days, provided that the extension is necessary due to matters beyond the control of HPN and HPN notifies the Member prior to the expiration of the initial thirty (30) day period of the circumstances requiring the extension and the date by which HPN expects to render a decision. If the extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information and the Member shall be afforded at least forty-five (45) days from receipt of the notice to provide the information. If HPN is unable to resolve the Members appeal as additional information ...
