Appeals of Adverse Determinations. A Claimant must appeal an adverse determination within 180 days after receiving written notice of the denial (or partial denial). An appeal may be made by a Claimant by means of written application to Humana, in person, or by mail, postage prepaid. A Claimant, on appeal, may request an expedited appeal of an adverse Urgent-care Claim decision orally or in writing. In such case, all necessary information, including the plan's benefit determination on review, will be transmitted between the plan and the Claimant by telephone, facsimile, or other available similarly expeditious method, to the extent permitted by applicable law. Determination of appeals of denied claims will be conducted promptly, will not defer to the initial determination and will not be made by the person who made the initial adverse claim determination or a subordinate of that person. The determination will take into account all comments, documents, records, and other information submitted by the Claimant relating to the claim. On appeal, a Claimant may review relevant documents and may submit issues and comments in writing. A Claimant on appeal may, upon request, discover the identity of medical or vocational experts whose advice was obtained on behalf of the plan in connection with the adverse determination being appealed, as permitted under applicable law. If the claims denial is based in whole, or in part, upon a medical judgment, including determinations as to whether a particular treatment, or other service is experimental, investigational, or not medically necessary or appropriate, the person deciding the appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The consulting health care professional will not be the same person who decided the initial appeal or a subordinate of that person. Time periods for decisions on appeal Appeals of claims denials will be decided and notice of the decision provided as follows: Urgent-care Claims As soon as possible but no later than 72 hours after Humana receives the appeal request. Pre-service Claims Within a reasonable period but no later than 30 days after Humana receives the appeal request. Post-service Claims Within a reasonable period but no later than 60 days after Humana receives the appeal request. Concurrent-care Decisions Within the time periods specified above depending on the type of claim involved. Appeals denial notices Notice of a c...
Appeals of Adverse Determinations. A. Internal Appeal Process First-level Appeals An adverse claim determination may be appealed within 180 days of the date of the original Explanation of Benefits by writing to: Delta Dental of Colorado Attn: Appeals PO Box 172528 Denver, CO 80217-2528 Additional information should be submitted in support of the appeal. Appeals are reviewed by an impartial Provider of the same or similar specialty as would typically manage the case being reviewed or by a Delta Dental claims specialist. The reviewing Provider will not have been involved in the initial decision. The decision will be sent to the Member with the rationale for the decision. The decision will be made within 30 calendar days for pre-Service denials. Post-Service decisions will be made within 60 calendar days.
