Appealing a Utilization Management Decision Sample Clauses

Appealing a Utilization Management Decision. If the Member or Member's provider disagrees with a utilization management decision, CareFirst will review the decision upon request. A utilization management appeal will be reviewed and decided upon by the CareFirst Medical Director or Associate Medical Director not involved in the initial denial decision. If necessary, the Medical Director or Associate Medical Director will discuss the Member's case with the Member's physician and/or request the opinion of a Specialist board certified in the same specialty as the treatment under review. Any non-certification or penalty may be appealed. Additional information is provided in the Benefit Determination and Appeals Attachment to this Evidence of Coverage on how to appeal a utilization management decision.
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Related to Appealing a Utilization Management Decision

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