COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. We want to know when a Member is dissatisfied about the care or services he receives from Blue Cross and Blue Shield of Louisiana, United Concordia Dental (UCD) or Participating Providers. If a Member wants to register a Complaint or file a formal written Grievance about Us, UCD or a Provider, please refer to the procedures below. A Member may be dissatisfied about decisions made regarding Covered Services. UCD considers an Appeal as the Member’s written request to change an Adverse Benefit Determination. Your Appeal rights are outlined below, after the Complaint and Grievance procedures. There is an Expedited Appeals process for situations where the time frame of the standard Dental Necessity Appeal would seriously jeopardize the life or health of a covered person or would jeopardize the covered person’s ability to regain maximum function.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. We want to know when a Member is dissatisfied about the care or services he receives from Blue Cross and Blue Shield of Louisiana or one of Our Providers. If a Member wants to register a Complaint or file a formal written Grievance about Us or a Provider, please refer to the procedures below. A Member may be dissatisfied about decisions We make regarding Covered Services. We consider an Appeal as the Member’s request to change an Adverse Benefit Determination made by the Company. Your Appeal rights are outlined below, after the Complaint and Grievance procedure. In addition to the Appeals rights, the Member’s Provider is given an opportunity to speak with a Medical Director for an Informal Reconsideration of Our coverage decision when they concern Medical Necessity determinations. We have expedited Appeals processes for situations where the time frame of the standard medical Appeals would seriously jeopardize the life or health of a covered person or would jeopardize the covered person’s ability to regain maximum function.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. We want to know when You are dissatisfied about the care or services received from Blue Cross and Blue Shield of Louisiana, United Concordia Dental (UCD), or Participating Providers. If You want to register a Complaint or file a formal written Grievance about Us, UCD or a Provider, please refer to the procedures below. You may be dissatisfied about decisions made regarding Covered Services. UCD considers an Appeal as Your written request to change an Adverse Benefit Determination. Your Appeal rights are outlined below, after the Complaint and Grievance procedures. There is an Expedited Appeals process for situations where the time frame of the standard Dental Necessity Appeal would seriously jeopardize the life or health of a covered person or would jeopardize the covered person’s ability to regain maximum function.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. 29 UNDERSTANDING THE BASICS OF YOUR COVERAGE
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. We want to know when a Member is unhappy about the care or services he receives from Blue Cross and Blue Shield of Louisiana or one of Our Providers. If a Member wants to register a Complaint or file a formal written Grievance about Us or a Provider, please refer to the procedures below. A Member may be unhappy about decisions We make regarding Covered Services. We consider the Member’s request to change Our coverage decision as an Appeal. We define an Appeal as a request from a Member or authorized representative to change a previous decision made by the Company about covered services. Examples of issues that qualify as Appeals include denied Authorizations, Claims based on Adverse Determinations of Medical Necessity, or Benefit determinations. Your Appeal rights are outlined below, after the Complaint and Grievance procedures. In addition to the Appeals rights, the Member’s Provider is given an opportunity to speak with a Medical Director for an Informal Reconsideration of Our coverage decision when they concern Medical Necessity determinations. We have an Expedited Appeals process for situations where the time frame of the standard Appeal would seriously jeopardize the life or health of a covered person or would jeopardize the covered person’s ability to regain maximum function.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. The Claims Administrator wants to know when a Plan Participant is unhappy about the care or services they receive from the Claims Administrator or one of its Providers. Plan Participants may register a Complaint, or file a formal written Grievance about the Claims Administrator or a Provider by following the procedures outlined below. Appeal rights for Plan Participants are outlined after the Complaint and Grievance Procedures. The Plan considers a Plan Participant’s request to change a coverage decision as an Appeal. An Appeal is defined as a request from a Plan Participant or their authorized representative to change a previous decision made by the Claims Administrator about Covered Services. Examples of issues that qualify as Appeals include denied Authorizations, Claims denied based on adverse determinations of Medical Necessity, or other adverse Benefit determinations. Adverse Benefit determinations include denials of and reductions in Benefit payments. In addition to the right to Appeal, the Plan Participant’s Provider is given an opportunity to speak with a Medical Director for an Informal Reconsideration of the Claims Administrator’s coverage decisions when the coverage decision concerns Medical Necessity or Investigational determinations. The Plan Participant may also have the right to review their file and present evidence or testimony as part of the internal Claims and Appeals process. An Expedited Appeal process is available for situations where the standard time frames would seriously jeopardize the life or health of a covered person, jeopardize the covered person’s ability to regain maximum function, or where in the opinion of the treating Physician, the covered person may experience pain that cannot be adequately controlled while awaiting a standard Appeal decision. That process is outlined following the first and second level Appeal procedures in Section B of this Article. The Claims Administrator will respond to your Appeal request within the timeframes allowed by law. The Appeal response will provide information sufficient to identify the Claim and include the following: • The date of service; healthcare Provider; Claim amount, if applicable; and diagnosis and treatment codes (the corresponding meanings of these codes will be provided upon request). • A description of the reason(s) for the denial, including a description of the standard, if any, applied in denying the Claim (for example, if a Medical Necessity standard was used in denying...
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. The Claims Administrator wants to know when a Plan Participant is dissatisfied with the quality of the care or services they receive from the Claims Administrator or one of its Providers. Plan Participants may register a Complaint, or file a formal written Grievance about the Claims Administrator or a Provider by following the procedures outlined below. The Plan considers a written Appeal as the Plan Participant’s request to change an Adverse Benefit Determination made by the Claims Administrator. An Appeal is defined as a request from a Plan Participant or their authorized representative to change a previous decision made by the Claims Administrator about Covered Services. Examples of issues that qualify as Appeals include denied Authorizations, Claims denied based on adverse determinations of Dental Necessity, or other Adverse Benefit Determinations. Adverse Benefit determinations include denials of and reductions in Benefit payments. Appeal rights for Plan Participants are outlined below, after the Complaint, Grievance and Informal Reconsideration Procedures. An expedited Appeal process is available for situations where the time frame of the standard Dental Appeal would seriously jeopardize the life or health of a covered person, jeopardize the covered person’s ability to regain maximum function.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. We want to know when a Member is dissatisfied about the care or services he receives from Blue Cross and Blue Shield of Louisiana, Xxxxx Vision or one of Our Providers. If a Member wants to register a Complaint or file a formal written Grievance about Us, Xxxxx Vision or a Provider, please refer to the procedures below. A Member may be dissatisfied about decisions made regarding Covered Services. Xxxxx Vision considers the Member’s request to change Our coverage decision as an Appeal. We define an Appeal as a written request from a Member or authorized representative to change a previous decision made by Us about covered services. Your Appeal rights are outlined below, after the Complaint and Grievance procedures. There is an Expedited Appeals process for situations where the timeframe of the standard Medical Necessity Appeal would seriously jeopardize the life or health of a covered person or would jeopardize the covered person’s ability to regain maximum function.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. 34 ERISA RIGHTS 37 MAKING PLAN CHANGES AND FILING CLAIMS 38 ARTICLE II. GENERAL PROVISIONS – GROUP/POLICYHOLDER ONLY 40 ARTICLE I. UNDERSTANDING THE BASICS OF YOUR COVERAGE NOTICE: THE MEMBER’S SHARE OF THEPAYMENT FOR COVERED SERVICES MAY BE BASED ON THE AGREEMENT BETWEEN THE MEMBER’S PLAN AND THE MEMBER’S PROVIDER. UNDER CERTAIN CIRCUMSTANCES, THISAGREEMENT MAY ALLOW THE MEMBER’S PROVIDER TO BILL THE MEMBER FOR AMOUNTS UP TO THE PROVIDER’S REGULAR BILLED CHARGES.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. CBH shall develop, implement and maintain a complaint and grievance system which provides for informal settlement of Members’ complaints and grievances at the lowest administrative level and a formal process for appeal (“Member Complaint and Grievance System”). The development and implementation of the Member Complaint and Grievance System shall be in complete accordance with the Commonwealth Contract and Applicable Law.
