Common use of Certification Process Clause in Contracts

Certification Process. When a pre-certification for a non-urgent service is requested from HealthPartners, an initial determination must be made within 15 calendar days. This time period may be extended for up to 14 days if you agree. If we request an extension we will notify you in advance of the extension and the reasons for the extension. When a pre-certification for an urgent service is requested from HealthPartners, an initial determination must be made within 72 hours, so long as all information reasonably needed to make a decision has been provided. In the event that you have not provided all information necessary to make a decision, you will be notified of such failure within 24 hours. You will then be given 48 hours to provide the requested information. You will be notified of the benefit determination within 48 hours after the earlier of HealthPartners receipt of the complete information or the end of the time granted to you to provide the specified additional information. If the determination is made to approve, we will notify your health care provider by telephone, and we may send written verification. If the initial determination is made not to approve, we will notify your health care provider and hospital, if appropriate, by telephone within one working day of the determination, and we will send written verification with details of the denial. If you want to request an expedited review, or have received a denial of a pre-certification and want to request an appeal, you have a right to do so. If your complaint is not resolved to your satisfaction under certain circumstances, you may request an external review. Refer to the information regarding Complaints and Appeals in section “Disputes and Complaints” for a description of how to proceed. How to contact CareCheck®: You may call (000)-000-0000 in the Minneapolis/St. Xxxx metro area or 0-000-000-0000 outside the metro area from 8:00 a.m. to 5:00 p.m. (Central Time) weekdays. You can leave a recorded message at other times. You may also write CareCheck® at Quality Utilization Management Department, 0000 00xx Xxxxxx Xxxxx, X.X. Box 1309, Minneapolis, MN 55440-1309. ACCESS TO RECORDS AND CONFIDENTIALITY‌ We comply with the state and federal laws governing the confidentiality and use of protected health information and medical or dental records. When your provider releases health information to us according to state law, we can use your protected health information when necessary, for certain health care operations, including, but not limited to: claims processing, including claims we make for reimbursement or subrogation; quality of care assessment and improvement; accreditation, credentialing, case management; care coordination and utilization management, disease management, the evaluation of potential or actual claims against us, auditing and legal services, and other health care operations. When you enrolled for coverage, you authorized our access to use your records as described in this paragraph, and this authorization remains in effect unless it is revoked.