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:
Appears in 4 contracts
Samples: Individual Epo Medical Policy, Individual Epo Medical Policy, Individual Epo Medical Policy
