Community Health Options’ Internal Appeal Process. Community Health Options will provide you with an Appeal process that is a full and fair review. Community Health Options will ensure the following:
Community Health Options’ Internal Appeal Process. Community Health Options will provide you with an Appeal process that is a full and fair review. Community Health Options will ensure the following:
1. The person(s) reviewing your Appeal will not be the same persons making the initial Claim Denial, and will not be subordinate to or supervised by the person making the initial Claim Denial;
2. If your Level I Appeal involves a Medical Necessity determination, at least one person reviewing your Appeal will be an appropriate medical professional with the same or similar medical specialty as involved in the Appeal;
3. You will have 180 days after receiving a Claim Denial to file an Appeal;
4. You will have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those materials or information were considered in the initial Claim Denial;
5. You will be provided upon request, at no cost, reasonable access to, and copies of, all documents, records, and other information relevant to or considered in making the initial Claim Denial;
6. The Appeal will be a “de novo” proceeding. This means that the reviewers will make the Appeal decision without considering or relying upon the initial Claim Denial; and
7. If the Appeal involves a Claim Denial based in some manner on medical judgment:
i. The Level I Appeal will be conducted by or in consultation with a medical professional in the same or similar medical specialty as the appealed service;
ii. The Appeal decision will include the title and qualifying credentials of the person conducting the review; and
iii. You will be provided with the identity and qualifications of any medical or vocational expert whose advice was considered, whether or not it was used in making the initial Claim Denial. Your Appeal rights include:
1. Being allowed to review the claim file and to present evidence and testimony as part of the Appeals process;
2. Being given, free of charge, any new or additional evidence considered, relied upon, or generated by Community Health Options (or at the direction of Community Health Options) in connection with the claim, unless the evidence is confidential or privileged. Community Health Options will give you the evidence as soon as possible and with enough time in advance of the decision to give you a reasonable opportunity to respond;
