Appeals of Adverse Benefit Determinations Sample Clauses

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 365 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. The HMO provides for two levels of Appeal of the adverse benefit determination. The Member must complete the two levels of HMO review before bringing a lawsuit against the HMO. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims. HMO Timeframe for Responding to an Adverse Benefit Determination Appeal or Complaint Review Type of Claim Level One Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Level Two Appeal or Complaint Review HMO Response Time from Receipt of Appeal or Complaint Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Within 36 hours. Review provided by HMO personnel not involved in making the adverse benefit determination. Within 36 hours. Review provided by HMO Appeals Committee. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care. Within 15 calendar days. Review provided by HMO personnel not involved in making the adverse benefit determination. Within 15 calendar days. Review provided by HMO Appeals Committee.

Appeals of Adverse Benefit Determinations. The covered person may submit an appeal if Aetna gives notice of an adverse benefit determination. This Plan provides for one level or two levels (Level Two only applies to dental, vision and hearing claims) of appeal. A final adverse benefit determination notice may also provide an option to request an External Review (if available). An appeal of an adverse benefit determination will be evaluated and reviewed by a clinical peer, not involved in the original determination. A clinical peer is: • A physician or other health care professional who holds a non-restricted license in a state of the US and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review. • For urgent care reviews concerning child or adolescent substance use disorder or mental disorder, holds a national board certification in child and adolescent psychiatry or a doctoral level psychology degree with training and clinical experience in the treatment of child and adolescent substance use and mental disorder as applicable. • For urgent care reviews concerning adult substance use or mental disorder, holds a national board certification in psychiatry, or a doctoral level psychology degree with training and clinical experience in the treatment of adult substance use and mental disorders, as applicable. The covered person has 180 calendar days with respect to Health Claims following the receipt of notice of an adverse benefit determination to request their Level One appeal. The covered person’s appeal must be submitted in writing and must include: • The covered person’s name. • The Policyholder's name. • A copy of Aetna’s notice of an adverse benefit determination. • The covered person’s reasons for making the appeal. • Any other information the covered person would like to have considered. The covered person can send their written appeal to Member Services at the address shown on their ID Card. The covered person may also choose to have another person (an authorized representative) make the appeal on their behalf. The covered person must provide written consent to Aetna. The covered person may be allowed to provide evidence or testimony during the appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or pre-service claim, a Physician may represent the Member in the Appeal. The HMO provides for two levels of Appeal of the adverse benefit determination. The Member must complete the two levels of HMO review before bringing a lawsuit against the HMO. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice. The following chart summarizes some information about how the Appeals are handled for different types of claims.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include important information including the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice or after the receipt of notification of a benefit denied due to a contractual exclusion except a request for a Level One Appeal of an urgent care claim may also be oral. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. The HMO provides for two levels of Appeal of the adverse benefit determination. If the HMO upholds an Adverse Benefit Determination at the First Level of Appeal, and the reason for the adverse determination was based on Medical Necessity, or experimental or investigational reasons, or a contractual exclusion and the Member presents evidence for a medical professional that there is a reasonable medical basis that the exclusion does not apply to the denied benefit, the Member or his/her authorized representative have the right to pursue an Appeal to an independent utilization review organization (IURO), or file the voluntary Level Two Appeal. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the HMO’s notice at the conclusion of the Level One Appeal explaining the Member’s right to make a Level Two Appeal. Any Member or Provider acting on behalf of a Member with the Member’s consent, who is dissatisfied with the results of a Level One Appeal, shall have the opportunity to pursue his or her Appeal before a panel of Physicians and/or other health care professionals with appropriate expertise who have not been involved in the Appeal and who has no direct financial interest in the Appeal or outcome of the review. The Member and/or an authorized representative may attend the Level Two Appeal hearing, question the representatives of HMO and present his/her case and any additional information the Member wishes. Upon request, the Member and HMO shall provide each other with any additional...

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination (including Coverage Decisions and Disputed Health Care Service decisions) from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing or by phone within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. The following chart summarizes some information about how the Appeals are handled for different types of claims.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 2 years from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal. The HMO provides for two levels of Appeal of the adverse benefit determination. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the notice to the following address. The following chart summarizes some information about how the Appeals are handled for different types of claims. Name: Aetna Health Inc. Title: Regional Medical Service Complaint and Appeals Unit Address: P.O. Box 10169, Van Nuys, CA 91410 Phone: 000-000-0000 Fax: 000-000-0000 HMO Timeframe for Responding to an Adverse Benefit Determination Appeal Type of Claim Level One Appeal HMO Response Time from Receipt of Appeal Level Two Appeal HMO Response Time from Receipt of Appeal Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. Pre-Service Claim. A claim for a benefit that requires approval of the benefit in advance of obtaining medical care.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made either orally or in writing within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf. In addition, in case of an urgent care claim or a pre-service claim, a Physician may also represent the Member in the Appeal. The HMO provides for one level of Appeal of the adverse benefit determination. The Member must complete that level of HMO review before bringing a lawsuit against the HMO. The following chart summarizes some information about how the Appeal is handled for different types of claims. The Appeal shall be conducted by a Physician who did not participate in the Utilization Review or adverse benefit determination at issue. However, in the case of an Appeal involving a medical or surgical specialty or subspecialty, HMO shall, upon request by a Member or their representative, utilize a board eligible or certified Physician in the appropriate specialty or subspecialty area to conduct the Appeal.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an adverse benefit determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice. A Member may also choose to have another person (an authorized representative) make the Appeal on the Member’s behalf by providing the HMO with written consent. However, in case of an urgent care claim or a pre-service claim, a Physician may represent the Member in the Appeal.

Appeals of Adverse Benefit Determinations. The Member will receive written notice of an Adverse Benefit Determination from the HMO. The notice will include the reason for the decision and it will explain what steps must be taken if the Member wishes to Appeal. The notice will also identify the Member’s rights to receive additional information that may be relevant to an Appeal. Requests for an Appeal must be made in writing within 180 calendar days from the date of the notice. However, Level One Appeals may also be requested orally. A Member, an authorized representative for the Member, or a Provider acting on behalf of a Member and with the Member’s consent, dissatisfied with a utilization management Adverse Benefit Determination will have the opportunity to Appeal. The HMO provides for two levels of Appeal of the Adverse Benefit Determination. The Member must complete the two levels of HMO review before pursuing an Appeal to an Independent Utilization Review Organization (IURO) or bringing a lawsuit against the HMO, unless serious or significant harm to the Member has occurred or will imminently occur. A Final Internal Adverse Benefit Determination notice will provide an option to request an External Review. If the Member decides to Appeal to the second level, the request must be made in writing within 60 calendar days from the date of the HMO’s notice at the conclusion of the Level One Appeal explaining the Member’s right to make a Level Two Appeal. Within 10 business days of receipt of an Utilization Review Level Two Appeal, the HMO will acknowledge the Appeal in writing. The following chart summarizes some information about how the Appeals are handled for different types of claims.

Appeals of Adverse Benefit Determinations. You may submit an appeal if Aetna gives notice of an adverse benefit determination. This Plan provides for two levels of appeal. It will also provide an option to request an external review of the adverse benefit determination. You have 180 calendar days following the receipt of notice of an adverse benefit determination to request your level one appeal. Your appeal may be submitted verbally or in writing and should include:  Your name;  Your employer’s name;  A copy of Aetna’s notice of an adverse benefit determination;  Your reasons for making the appeal; and  Any other information you would like to have considered. The notice of an adverse benefit determination will include the address where the appeal can be sent. If your appeal is of an urgent nature, you may call Aetna’s Customer Service Unit at the toll-free phone number on your ID card. You may also choose to have another person (an authorized representative) make the appeal on your behalf by providing verbal or written consent to Aetna. Level One Appeal - Group Health Claims A level one appeal of an adverse benefit determination shall be provided by Aetna personnel not involved in making the adverse benefit determination. Urgent Care Claims (May Include concurrent care claim reduction or termination) Aetna shall issue a decision within 36 hours of receipt of the request for an appeal. Pre-Service Claims (May Include concurrent care claim reduction or termination) Aetna shall issue a decision within 15 calendar days of receipt of the request for an appeal.