External Appeals For appeals of a decision that a prescription drug is not covered because it is not on our formulary, please see the Formulary Exception Process in the Prescription Drug and Diabetic Equipment and Supplies section. When filing a reconsideration or an appeal, please provide the same information listed in the Complaints section above.
Personal accounts With a personal account you can send and request money from friends and family and pay online for purchases. Holders of certain existing personal accounts may be required to upgrade their accounts (which may include providing further information to PayPal) to be able to use all of the current functionality available in a personal account. To use your PayPal account primarily to sell things, you must open a business account or convert your personal account to a business account. You should take reasonable steps to stop your PayPal account being misused. You must maintain adequate security and control of any and all devices, items, IDs, passwords and personal identification numbers / codes that you use to access your PayPal account and the PayPal services. You must comply with all reasonable instructions we may issue regarding how you can keep your Payment Instrument safe. We may require you to authenticate any instruction relating to your account (i.e. give us the information that we need to be sure that it’s you giving us the instruction, such as submitting your correct log-in information – this could include your e-mail address and password) and otherwise successfully log into your PayPal account to provide to us your instruction. You must keep your postal address, email address, phone number of a phone to which you are the primary user and other contact information current in your PayPal account profile. You may expressly grant, remove and manage permissions for some third parties to take certain actions on your behalf. In some cases you can do this when logged into your account – in other cases you can do this directly with the third party. You acknowledge that if you grant permission for a third party to take actions on your behalf, we may disclose certain information about your Account to this third party. You may permit third party service providers licensed by applicable law to: • provide account information services to access information about your account on your behalf; • confirm whether an amount necessary for the execution of a card-based payment transaction is available on your account; or • provide payment initiation services to initiate payments from your account on your behalf. Granting permission to any third party to access your account in any way does not relieve you of any of your responsibilities under this user agreement. You are liable to us for the actions that you authorise the third parties to carry out. You will not hold us responsible for, and you will indemnify us from, any liability arising from the actions or inactions of such third parties in connection with the permissions you granted, subject to your mandatory legal rights.
How to Request an External Appeal If you remain dissatisfied with our medical appeal determination, you may request an external review by an outside review agency. In accordance with §27-18.9-8, your external appeal will be reviewed by one of the external independent review organizations (IRO) approved by the Office of the Health Insurance Commissioner. The IRO is selected using a rotational method. Your claim does not have to meet a minimum dollar threshold in order for you to be able to request an external appeal. To request an external appeal, submit a written request to us within four (4) months of your receipt of the medical appeal denial letter. We will forward your request to the outside review agency within five (5) business days, unless it is an urgent appeal, and then we will send it within two (2) business days. We may charge you a filing fee up to $25.00 per external appeal, not to exceed $75.00 per plan year. We will refund you if the denial is reversed and will waive the fee if it imposes an undue hardship for you. Upon receipt of the information, the outside review agency will notify you of its determination within ten (10) calendar days, unless it is an urgent appeal, and then you will be notified within seventy-two (72) hours. The determination by the outside review agency is binding on us. Filing an external appeal is voluntary. You may choose to participate in this level of appeal or you may file suit in an appropriate court of law (see Legal Action, below). Once a member or provider receives a decision at one of the several levels of appeals noted above, (reconsideration, appeal, external), the member or provider may not ask for an appeal at the same level again, unless additional information that could affect such decisions can be provided.
