Common use of Administrative Appeals Clause in Contracts

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your provider did not follow BCBSRI’s requirements; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: • thirty (30) calendar days for a prospective review; and • sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination.

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your provider did not follow BCBSRI’s requirements; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service DepartmentMedicare Concierge Team, a Customer Service Representative representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. We will acknowledge receipt of your administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: • thirty (30) calendar days for a prospective review; : and • sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination.

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your provider did not follow BCBSRI’s requirements; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: within • thirty (30) calendar days for a prospective review; : and • sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination.

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: •  the services were excluded from coverage; •  we determined that you were not eligible for coverage; •  you or your provider did not follow BCBSRI’s requirements; or •  a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. We will acknowledge receipt of your administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: • thirty (30) calendar days for a prospective review; and • within sixty (60) calendar days for a retrospective reviewof the date it was received. The letter will provide you with information regarding our determination.

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your provider did not follow BCBSRI’s requirements, including providing notification of service, when applicable; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: within • thirty (30) calendar days for a prospective review; : and • sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination.

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your provider did not follow BCBSRI’s requirements; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. We will acknowledge receipt of your administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: • thirty (30) calendar days for a prospective review; and • within sixty (60) calendar days for a retrospective reviewof the date it was received. The letter will provide you with information regarding our determination.

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: •  the services were excluded from coverage; •  we determined that you were not eligible for coverage; •  you or your provider did not follow BCBSRI’s requirements; or •  a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: •  thirty (30) calendar days for a prospective review; and •  sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination.

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: •  the services were excluded from coverage; •  we determined that you were not eligible for coverage; •  you or your provider did not follow BCBSRI’s requirements; or •  a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service DepartmentMedicare Concierge Team, a Customer Service Representative representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. We will acknowledge receipt of your administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: •  thirty (30) calendar days for a prospective review; : and •  sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination.

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your provider did not follow BCBSRI’s requirements, including providing notification of service, when applicable; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: • thirty (30) calendar days for a prospective review; and • sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination.