Expedited Appeal. An Appeal of a review of continued or extended health care services, additional services rendered in the course of continued treatment, home health care services following discharge from an inpatient Hospital admission, services in which a Provider requests an immediate review, or any other urgent matter will be handled on an expedited basis. An expedited Appeal is not available for retrospective reviews. For an expedited Appeal, Your Provider will have reasonable access to the clinical peer reviewer assigned to the Appeal within one (1) business day of receipt of the request for an Appeal. Your Provider and a clinical peer reviewer may exchange information by telephone or fax. An expedited Appeal will be determined within the earlier of 72 hours of receipt of the Appeal or two
Expedited Appeal. An Appeal of a review of continued or extended health care services, additional services rendered in the course of continued treatment, home health care services following discharge from an inpatient Hospital admission, services in which a Provider requests an immediate review, or any other urgent matter will be handled on an expedited basis. An expedited Appeal is not available for retrospective reviews. For an expedited Appeal, Your Provider will have reasonable access to the clinical peer reviewer assigned to the Appeal within one (1) business day of receipt of the request for an Appeal. Your Provider and a clinical peer reviewer may exchange information by telephone or fax. An expedited Appeal will be determined within the earlier of 72 hours of receipt of the Appeal or two (2) business days of receipt of the information necessary to conduct the Appeal. If You are not satisfied with the resolution of Your expedited Appeal, You may file a standard internal appeal or an external appeal. Our failure to render a determination of Your Appeal within 60 calendar days of receipt of the necessary information for a standard Appeal or within two (2) business days of receipt of the necessary information for an expedited Appeal will be deemed a reversal of the initial adverse determination.
Expedited Appeal. The Insured can ask (either orally or in writing) for an Expedited Appeal of an Adverse Benefit Determination for a Pre-Service Claim that involves an Urgent Care Claim if the Insured or his Physician believe that the health of the Insured could be seriously harmed by waiting for a routine appeal decision. Expedited Appeals are not available for appeals regarding denied claims for benefit payment (Post-Service Claim) or for Pre-Service Claims that are not Urgent Care Claims. Expedited Appeals must be decided no later than seventy-two (72) hours after receipt of the appeal, provided all necessary information has been submitted to SHL. If the initial notification was oral, SHL shall provide a written or electronic explanation to the Insured within seventy-two (72) hours after the expedited appeal being filed. If insufficient information is received, SHL shall notify the Insured as soon as possible, but no later than twenty-four (24) hours after receipt of the claim of the specific information necessary to complete the claim. The Insured will be afforded a reasonable amount of time, taking into account the circumstances, but not less than forty-eight (48) hours, to provide the specified information. SHL shall notify the Insured of the benefit determination as soon as possible, but in no case later than forty-eight (48) hours after the earlier of: SHL’s receipt of the specified information, or The end of the period afforded the Insured to provide the specified information. If the Insured’s Physician requests an Expedited Appeal, or supports an Insured’s request for an Expedited Appeal, and indicates that waiting for a routine appeal could seriously harm the health of the Insured or subject the Insured to unmanageable severe pain that cannot be adequately managed without care or treatment that is the subject of the Claim for Benefits, SHL will automatically grant an Expedited Appeal. If a request for an Expedited Appeal is submitted without support of the Insured’s Physician, SHL shall decide whether the Insured’s health requires an Expedited Appeal. If an Expedited Appeal is not granted, SHL will provide a decision within thirty (30) days, subject to the routine appeals process for Pre-Service Claims.
Expedited Appeal. The accelerated process by which the Contractor must respond to an Appeal by an Enrollee if a denial of care decision by the Contractor may jeopardize life, health, or ability to attain, maintain, or regain maximum function, as determined by the Contractor.
Expedited Appeal. The accelerated process by which a STAR+PLUS MMP must respond to an Appeal by an Enrollee if a decision by a STAR+PLUS MMP may jeopardize life, health, or ability to attain, maintain, or regain maximum function.
Expedited Appeal. The accelerated process by which an ICO must respond to an appeal by an Enrollee if a denial of care decision by an ICO may jeopardize life, health or ability to attain, maintain or regain maximum function.
Expedited Appeal. An Appeal of a review of continued or extended health care services, additional services rendered in the course of continued treatment, home health care services following discharge from an inpatient Hospital admission, services in which a Provider requests an immediate review, or any other urgent matter will be handled on an expedited basis. An expedited Appeal is not available for retrospective reviews. For an expedited Appeal, Your Provider will have reasonable access to the clinical peer reviewer assigned to the Appeal within one (1) business day of receipt of the request for an Appeal. Your Provider and a clinical peer reviewer may exchange information by telephone or fax. An expedited Appeal will be determined within the earlier of 72 hours of receipt of the Appeal or two (2) business days of receipt of the information necessary to conduct the Appeal. If You are not satisfied with the resolution of Your expedited Appeal, You may file a standard internal appeal or an external appeal. Our failure to render a determination of Your Appeal within 30 calendar days of receipt of the necessary information for a standard Appeal or within two (2) business days of receipt of the necessary information for an expedited Appeal will be deemed a reversal of the initial adverse determination.
I. Full and Fair Review of an Appeal. We will provide You, free of charge, with any new or additional evidence considered, relied upon, or generated by Us or any new or additional rationale in connection with Your Appeal. The evidence or rationale will be provided as soon as possible and sufficiently in advance of the date on which the notice of final adverse determination is required to be provided to give You a reasonable opportunity to respond prior to that date.
Expedited Appeal. An expedited appeal may be submitted orally or in writing. All necessary information, including our determination on review, will be transmitted between the claimant and us by telephone, facsimile, or other available similarly expeditious method. For an appeal to be processed as expedited at least one of the following must apply:
Expedited Appeal. An expedited appeal may be submitted orally or in writing. All necessary information, including our determination on review, will be transmitted between the member and us by telephone, facsimile, or other available similarly expeditious method. An expedited appeal shall be resolved as expeditiously as the member’s health condition requires but not more than 24 hours after receipt of the grievance. Due to the 24-hour resolution timeframe, the standard requirements for notification, grievance panel, and acknowledgement do not apply. The provider who recommended the service and/or the member’s PCP, along with the member, shall be notified orally of the decision followed-up by a written notice of the determination. Upon written request, we will mail or electronically mail a copy of the member’s complete contract to the member or the member’s authorized representative as expeditiously as the expedited appeal is handled.
Expedited Appeal. An expedited appeal is available for emergency care, life-threatening conditions, and hospitalized enrollees. An expedited appeal is also available for denials of Prescription Drugs and intravenous infusions for which the enrollee is currently receiving benefits. An expedited appeal is also available for a denied step therapy protocol exception request. ● Specialty Appeal: This appeal is available only after we decide the initial appeal. Your health care provider can request a particular type of specialty provider review the case, the appeal or the decision denying the appeal must be reviewed by a health care provider in the Same or Similar Specialty that typically manages the medical, dental, or specialty condition, procedure, or Treatment under discussion for review. Your provider must request the appeal no later than 10 working days after the date the appeal is denied. We will complete the review within 15 working days of receipt of the request. We will provide a letter of acknowledgement of the appeal within five (5) working days from our receipt of the appeal. This letter will include: acknowledgement of the date we received the appeal; a list of relevant documents needed to be submitted to us; and an appeal form to be completed if the appeal was received by us orally for review of the appeal. The Adverse Determination Appeal Process includes the following:
