Common use of Beginning Your Appeal Clause in Contracts

Beginning Your Appeal. If you wish to Appeal an Adverse Benefit Determination, Adverse Health Care Treatment Decision, or Adverse Benefit Determination not involving a Health Care Treatment Decision, you must submit your Appeal to Community Health Options within 180 days from the correspondence date of the decision you wish to Appeal. If you do not submit an Appeal within this time limit, you will lose your right to Appeal the decision unless the delay is reasonable under the circumstances and does not negatively prejudice Community Health Options’ rights. You will need to give us specific information about your Appeal, including: a. Which decision(s) you are Appealing; b. Why you disagree with the decision(s); and c. What you would like the outcome to be. Please provide as much information as possible, including: your Member ID number, Claim numbers, reference numbers, dates of service, Provider names, and any other information that will help us identify the Claims or Services you wish to Appeal. We may need to review your medical records, billing statements, and other documents to decide your Appeal. If we need more information (such as medical records, bills, or other documents) to process your Appeal, your Appeals Coordinator will let you know. Please send your Appeal to: Community Health Options Attn: Appeals Coordinator Mail Stop 800 P.O. Box 1121 Lewiston, ME 04243 Telephone: 1‐855‐624‐6463 (TTY/TDD: 711) Fax: 1‐877‐314‐5693 Email: xxxxxxx@xxxxxxxxxxxxx.xxx After we receive your Appeal, an Appeals Coordinator will manage your Appeal throughout the entire Appeal process. We will send you a letter acknowledging receipt of the Appeal and your Appeals Coordinator within three business days after we receive your Appeal. The letter will describe the Appeal process and your rights in more detail. Please contact your Appeals Coordinator if you have questions.

Beginning Your Appeal. If you wish to Appeal an Adverse Benefit Determination, Adverse Health Care Treatment Decision, or Adverse Benefit Determination not involving a Health Care Treatment Decision, you must submit your Appeal to Community Health Options within 180 days from the correspondence date of the decision you wish to Appeal. If you do not submit an Appeal within this time limit, you will lose your right to Appeal the decision unless the delay is reasonable under the circumstances and does not negatively prejudice Community Health Options’ rights. You will need to give us specific information about your Appeal, including: a. Which decision(s) you are Appealing; b. Why you disagree with the decision(s); and c. What you would like the outcome to be. Please provide as much information as possible, including: your Member ID number, Claim numbers, reference numbers, dates of service, Provider names, and any other information that will help us identify the Claims or Services you wish to Appeal. We may need to review your medical records, billing statements, and other documents to decide your Appeal. If we need more information (such as medical records, bills, or other documents) to process your Appeal, your Appeals Coordinator will let you know. Please send your Appeal to: Community Health Options Attn: Appeals Coordinator Mail Stop 800 100 P.O. Box 1121 Lewiston, ME 04243 Telephone: 1‐855‐624‐6463 0-000-000-0000 (TTY/TDD: 711) Fax: 1‐877‐314‐5693 Email: xxxxxxx@xxxxxxxxxxxxx.xxx 000-000-0000 After we receive your Appeal, an Appeals Coordinator will manage your Appeal throughout the entire Appeal process. We will send you a letter acknowledging receipt of the Appeal and identifying your Appeals Coordinator within three business days after we receive your Appeal. The letter will describe the Appeal process and your rights in more detail. Please contact your Appeals Coordinator if you have questions.

Beginning Your Appeal. If you wish to Appeal an Adverse Benefit Determination, Adverse Health Care Treatment Decision, or Adverse Benefit Determination not involving a Health Care Treatment Decision, you must submit your Appeal to Community Health Options within 180 days from the correspondence date of the decision you wish to Appeal. If you do not submit an Appeal within this time limit, you will lose your right to Appeal the decision unless the delay is reasonable under the circumstances and does not negatively prejudice Community Health Options’ rights. You will need to give us specific information about your Appeal, including: a. Which decision(s) you are Appealing; b. Why you disagree with the decision(s); and c. What you would like the outcome to be. Please provide as much information as possible, including: your Member ID number, Claim numbers, reference numbers, dates of service, Provider names, and any other information that will help us identify the Claims or Services you wish to Appeal. We may need to review your medical records, billing statements, and other documents to decide your Appeal. If we need more information (such as medical records, bills, or other documents) to process your Appeal, your Appeals Coordinator will let you know. Please send your Appeal to: Community Health Options Attn: Appeals Coordinator Mail Stop 800 P.O. Box 1121 Lewiston, ME 04243 Telephone: 1‐855‐624‐6463 0-000-000-0000 (TTY/TDD: 711) Fax: 1‐877‐314‐5693 0-000-000-0000 Email: xxxxxxx@xxxxxxxxxxxxx.xxx After we receive your Appeal, an Appeals Coordinator will manage your Appeal throughout the entire Appeal process. We will send you a letter acknowledging receipt of the Appeal and identifying your Appeals Coordinator within three business days after we receive your Appeal. The letter will describe the Appeal process and your rights in more detail. Please contact your Appeals Coordinator if you have questions.

Beginning Your Appeal. If you wish to Appeal an Adverse Benefit Determination, Adverse Health Care Treatment Decision, or Adverse Benefit Determination not involving a Health Care Treatment Decision, you must submit your Appeal to Community Health Options within 180 days from the correspondence date of the decision you wish to Appeal. If you do not submit an Appeal within this time limit, you will lose your right to Appeal the decision unless the delay is reasonable under the circumstances and does not negatively prejudice Community Health Options’ rights. SAMPLE You will need to give us specific information about your Appeal, including: a. Which decision(s) you are Appealing; b. Why you disagree with the decision(s); and c. What you would like the outcome to be. Please provide as much information as possible, including: your Member ID number, Claim numbers, reference numbers, dates of service, Provider names, and any other information that will help us identify the Claims or Services you wish to Appeal. We may need to review your medical records, billing statements, and other documents to decide your Appeal. If we need more information (such as medical records, bills, or other documents) to process your Appeal, your Appeals Coordinator will let you know. Please send your Appeal to: Community Health Options Attn: Appeals Coordinator Mail Stop 800 P.O. Box 1121 Lewiston, ME 04243 Telephone: 1‐855‐624‐6463 0-000-000-0000 (TTY/TDD: 711) Fax: 1‐877‐314‐5693 0-000-000-0000 Email: xxxxxxx@xxxxxxxxxxxxx.xxx After we receive your Appeal, an Appeals Coordinator will manage your Appeal throughout the entire Appeal process. We will send you a letter acknowledging receipt of the Appeal and identifying your Appeals Coordinator within three business days after we receive your Appeal. The letter will describe the Appeal process and your rights in more detail. Please contact your Appeals Coordinator if you have questions.

Beginning Your Appeal. If you wish to Appeal an Adverse Benefit Determination, Adverse Health Care Treatment Decision, or Adverse Benefit Determination not involving a Health Care Treatment Decision, you must submit your Appeal to Community Health Options within 180 days from the correspondence date of the decision you wish to Appeal. If you do not submit an Appeal within this time limit, you will lose your right to Appeal the decision unless the delay is reasonable under the circumstances and does not negatively prejudice Community Health Options’ rights. You will need to give us specific information about your Appeal, including: a. Which decision(s) you are Appealing; b. Why you disagree with the decision(s); and c. What you would like the outcome to be. Please provide as much information as possible, including: your Member ID number, Claim numbers, reference numbers, dates of service, Provider names, and any other information that will help us identify the Claims or Services you wish to Appeal. We may need to review your medical records, billing statements, and other documents to decide your Appeal. If we need more information (such as medical records, bills, or other documents) to process your Appeal, your Appeals Coordinator will let you know. Please send your Appeal to: Community Health Options Attn: Appeals Coordinator Mail Stop 800 P.O. Box 1121 Lewiston, ME 04243 Telephone: 1‐855‐624‐6463 0-000-000-0000 (TTY/TDD: 711) Fax: 1‐877‐314‐5693 0-000-000-0000 Email: xxxxxxx@xxxxxxxxxxxxx.xxx After we receive your Appeal, an Appeals Coordinator will manage your Appeal throughout the entire Appeal process. We will send you a letter acknowledging receipt of the Appeal and identifying your Appeals Coordinator within three business days after we receive your Appeal. The letter will describe the Appeal process and your rights in more detail. Please contact your Appeals Coordinator if you have questions.

Beginning Your Appeal. SAMPLE If you wish to Appeal an Adverse Benefit Determination, Adverse Health Care Treatment Decision, or Adverse Benefit Determination not involving a Health Care Treatment Decision, you must submit your Appeal to Community Health Options within 180 days from the correspondence date of the decision you wish to Appeal. If you do not submit an Appeal within this time limit, you will lose your right to Appeal the decision unless the delay is reasonable under the circumstances and does not negatively prejudice Community Health Options’ rights. You will need to give us specific information about your Appeal, including: a. Which decision(s) you are Appealing; b. Why you disagree with the decision(s); and c. What you would like the outcome to be. Please provide as much information as possible, including: your Member ID number, Claim numbers, reference numbers, dates of service, Provider names, and any other information that will help us identify the Claims or Services you wish to Appeal. We may need to review your medical records, billing statements, and other documents to decide your Appeal. If we need more information (such as medical records, bills, or other documents) to process your Appeal, your Appeals Coordinator will let you know. Please send your Appeal to: Community Health Options Attn: Appeals Coordinator Mail Stop 800 P.O. Box 1121 Lewiston, ME 04243 Telephone: 1‐855‐624‐6463 0-000-000-0000 (TTY/TDD: 711) Fax: 1‐877‐314‐5693 0-000-000-0000 Email: xxxxxxx@xxxxxxxxxxxxx.xxx After we receive your Appeal, an Appeals Coordinator will manage your Appeal throughout the entire Appeal process. We will send you a letter acknowledging receipt of the Appeal and identifying your Appeals Coordinator within three business days after we receive your Appeal. The letter will describe the Appeal process and your rights in more detail. Please contact your Appeals Coordinator if you have questions.

Beginning Your Appeal. If you wish to Appeal an Adverse Benefit Determination, Adverse Health Care Treatment Decision, or Adverse Benefit Determination not involving a Health Care Treatment Decision, you must submit your Appeal to Community Health Options within 180 days from the correspondence date of the decision you wish to Appeal. If you do not submit an Appeal within this time limit, you will lose your right to Appeal the decision unless the delay is reasonable under the circumstances and does not negatively prejudice Community Health Options’ rights. You will need to give us specific information about your Appeal, including: a. Which decision(s) you are Appealing; b. Why you disagree with the decision(s); and c. What you would like the outcome to be. Please provide as much information as possible, including: your Member ID number, Claim numbers, reference numbers, dates of service, Provider names, and any other information that will help us identify the Claims or Services you wish to Appeal. We may need to review your medical records, billing statements, and other documents to decide your Appeal. If we need more information (such as medical records, bills, or other documents) to process your Appeal, your Appeals Coordinator will let you know. Please send your Appeal to: Community Health Options Attn: Appeals Coordinator Mail Stop 800 P.O. Box 1121 Lewiston, ME 04243 Telephone: 1‐855‐624‐6463 (TTY/TDD: 711) Fax: 1‐877‐314‐5693 Email: xxxxxxx@xxxxxxxxxxxxx.xxx After we receive your Appeal, an Appeals Coordinator will manage your Appeal throughout the entire Appeal process. We will send you a letter acknowledging receipt of the Appeal and identifying your Appeals Coordinator within three business days after we receive your Appeal. The letter will describe the Appeal process and your rights in more detail. Please contact your Appeals Coordinator if you have questions.