Common use of Complaint Appeals Clause in Contracts

Complaint Appeals. If your complaint regarding an administrative operation or matter or a post-service claim is not resolved to your satisfaction, then within 60 calendar days after receiving notice that your complaint was wholly or partially denied, you or your authorized representative may request an appeal. Your appeal can be submitted to PIC in writing, along with any issues, comments, and additional information as appropriate. You have the right to present written evidence and telephonic testimony as part of the appeals process for any appeal that involves a medical determination in its resolution, but only with respect to the resolution of the medical determination aspect. Within 30 calendar days after any written appeal requiring a medical determination in its resolution is received by PIC, you will receive written notice of PIC’s decision, including the specific reasons for it and the procedure for requesting an external review to the extent external review is required by law. Within 30 calendar days after any other written appeal is received by PIC, you will receive written notice of PIC’s decision, including the specific reasons for it. These time periods may be extended for up to an additional 14 calendar days if you agree.