Expedited Appeals. The expedited Appeal process is available for review of the Adverse Benefit Determination involving a situation where the time frame of the standard medical Appeal would seriously jeopardize the Member’s life, health or ability to regain maximum function. It includes a situation where, in the opinion of the treating physician, the Member may experience pain that cannot be adequately controlled while awaiting a standard Medical Appeal decision. An Expedited Appeal also includes requests concerning an Admission, availability of care, continued stay, or healthcare service for a Member currently in the emergency room, under observation, or receiving Inpatient care. An Expedited External Appeal is also available if the Adverse Benefit Determination involves a denial of coverage based on a determination that the recommended or requested healthcare service or treatment is deemed experimental or Investigational; and the covered person's treating Physician certifies in writing that the recommended or requested healthcare service or treatment that is the subject of the Adverse Benefit Determination would be significantly less effective if not promptly initiated. Expedited Appeals are not provided for review of services previously rendered. An Expedited Appeal shall be made available to, and may be initiated by the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf. Requests for an Expedited Appeal may be verbal or written. For verbal Expedited Appeals, call 0-000-000-0000 or 0-000-000-0000. For written Expedited Appeals, fax 000-000-0000 or mail to: Blue Cross and Blue Shield of Louisiana Expedited Appeal - Medical Appeals P. O. Box 98022 Baton Rouge, LA 70898-9022
Expedited Appeals. An expedited appeal determination may be provided to the appealing party by telephone or electronic transmission and shall be followed with a letter within three (3) working days of the initial telephonic or electronic notification. In a circumstance involving an Insured’s Life Threatening condition, denials of Prescription Drugs and intravenous infusions that are currently being received, or if our internal appeal process timelines are not met, the Insured is entitled to an immediate appeal to an external review and is not required to comply with procedures for an internal review of the Adverse Determination. Timeline for Resolution
Expedited Appeals. 1. The Health Plan shall have an expedited review process for appeals for use when taking the time for a standard resolution could seriously jeopardize the enrollee’s life or health or ability to attain, maintain or regain maximum function.
Expedited Appeals. If you are appealing an Adverse Decision that involves an Urgent Medical Condition, you may request an expedited decision by contacting Health Plan: During Regular Business Hours Monday through Friday from 7:30am – 5:30pm – The Member should contact the Member Services Department. Inside the Washington, D.C. Metropolitan area (000) 000-0000 Outside the Washington, D.C. Metropolitan area 0-000-000-0000. During Non-Business Hours The Member should call the Advice/Appointment Line. Inside the Washington, D.C. Metropolitan area (000) 000-0000 Outside the Washington, D.C. Metropolitan area 0-000-000-0000 Once an expedited appeal is initiated, clinical review will determine if the appeal involves an Urgent Medical Condition. If the appeal does not meet the criteria for an expedited appeal, the request will be managed as a formal appeal, as described above. If such a decision is made, Health Plan will call the Member within 24 hours. If the request for appeal meets the criteria for an expedited appeal, the appeal will be reviewed by a Plan Physician who is board certified or eligible in the same specialty as the treatment under review, and who is not the individual (or the individual’s subordinate) who made the initial adverse decision. If additional information is needed to proceed with the review, the Member or the Authorized Representative will be contacted by telephone or facsimile. Expedited Appeal Decisions An expedited appeal will be concluded as soon as possible after receipt of all necessary documentation by Health Plan, but not later than 24 hours after receipt of the request for appeal. Health plan will notify you of its decision immediately by telephone. If the Service is approved, Health Plan will provide assistance in arranging the authorized Service. If the Service is denied, written notice of its decision will be sent within one business day after that. Notification of Adverse Appeal Decisions If the review results in a denial, Health Plan will notify the Member and the Authorized Representative in writing. The notification shall include:
Expedited Appeals. You or your doctor may want us to make a fast decision. You can ask for an expedited review if you or your doctor feel that your health is at risk. Your doctor must send information in writing telling us why you need a faster review. Expedited appeal reviews are available for members in situations deemed urgent. If Ambetter from Sunshine Health agrees that the request is urgent, your appeal will be resolved within 72 hours. Who May File an Appeal? You, the member (or the guardian of a minor member). A person you have authorized to act for you. You must give written permission if someone else files an appeal for you. Ambetter from Sunshine Health will include a form with the Notice of Action. Contact Member Services at 0-000-000-0000 if you need help. We can assist you with filing an appeal. When does an Appeal Have to be Filed? The Notice of Action will tell you about this process. You may file an appeal within 180 days from the date of the Notice of Action. If you make your request by phone, you must also send Ambetter from Sunshine Health a letter confirming your request within 10 days of making the request by phone. Ambetter from Sunshine Health will give you a written decision within 30 days (if the service has not been provided) or 60 days (if the service has already been provided) of the date we receive your written request. You, or someone authorized to do so, can act for you or help you with the appeal. You can tell us the name of the person authorized to help you by completing a Request for an Appeal or Grievance Form. We can help you fill out this form. Call us at 000-000-0000 or TTY/TDD at 000-000-0000 to ask for help, including if you need an interpreter. You may send us health information about why we should pay for the service. This information can be sent with the Request for an Appeal or Grievance Form or in a separate letter. You can call your doctor if you need more medical information for your appeal. In some cases, getting the health information may take extra time. The time for deciding your appeal can be extended for 14 days if you or your doctor thinks the extra time to get the health information will benefit you. If Ambetter from Sunshine Health requests more time to gather the health information, we will send you a letter to tell you why. This extension will be for 14 days. We will only do this if the health information we are waiting for could help with your plan appeal. You may send the Request for an Appeal or Grievance Form...
Expedited Appeals. You may request in writing or verbally that the appeal process be expedited if, (a) the time frames under this process would seriously jeopardize Your life, health or ability to regain maximum function or in the opinion of Your Physician would cause You severe pain which cannot be managed without the requested services; or (b) Your appeal involves non-authorization of an admission or continuing inpatient Hospital stay If you believe you are eligible for and request an expedited appeal from Cigna, you may be eligible to request an expedited external review from NCDOI. Expedited external review is available if you have a medical condition where the time frame for completion of an expedited appeal with us would reasonably be expected to seriously jeopardize your life or health, or jeopardize your ability to regain maximum function. However, you must have also filed a request for an expedited appeal (even if you have not yet received a decision on the appeal) before NCDOI can accept your request for expedited external review. Cigna's Physician reviewer, in consultation with the treating Physician will decide if an expedited appeal is necessary. When an appeal is expedited, We will consult with consult with Physician who is licensed to practice medicine in North Carolina, and will respond orally with a decision within 72 hours, followed up in writing within the lesser of two working days or four calendar days. If the expedited review is a concurrent review determination, Cigna will remain liable for health care services until the Insured Person has been notified of the determination. You may contact the North Carolina Department of Insurance for assistance at: North Carolina Department of Insurance Health Insurance Smart NC 0000 Xxxx Xxxxxxx Xxxxxx Xxxxxxx, XX 00000-0000 Fax: 0-000-000-0000 Telephone: 0-000-000-0000 Telephone:0-000-000-0000(Toll-free) xxx.xxxxx.xxx/Xxxxx .
Expedited Appeals. If you are appealing an Adverse Decision that involves an Urgent Medical Condition, you may request an expedited decision by contacting Member Services Monday through Friday between 7:30 a.m. and 9 p.m. at 0-000-000-0000 or 711 (TTY). Once an expedited Appeal is initiated, clinical review will determine if the Appeal involves an Urgent Medical Condition. If the Appeal does not meet the criteria for an expedited Appeal, the request will be managed as a formal Appeal, as described above. If such a decision is made, the Health Plan will call the Member within twenty-four (24) hours. If the request for Appeal meets the criteria for an expedited Appeal, the Appeal will be reviewed by a Plan Physician who is board certified or eligible in the same specialty as the treatment under review, and who is not the individual (or the individual’s subordinate) who made the initial adverse decision. If additional information is needed to proceed with the review, you or your Authorized Representative will be contacted by telephone or facsimile.
Expedited Appeals. An expedited appeal determination may be provided to the appealing party by telephone or electronic transmission and shall be followed with a letter within three working days of the initial telephonic or electronic notification. In a circumstance involving an Insured’s Life Threatening condition, denials of prescription drugs and intravenous infusions that are currently being received, or if our internal appeal process timelines are not met, the Insured is entitled to an immediate appeal to an external review and is not required to comply with procedures for an internal review of the Adverse Determination. Timeline for Resolution Preservice Urgent: No later than 72 hours from the date all necessary information has been received Preservice (non-urgent): 15 days Post-Service: 30 days
Expedited Appeals. 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 Appeals. The Claims Administrator provides an Expedited Appeal process for review of an adverse determination involving a situation where the time frame of the standard Appeal would seriously jeopardize the Plan Participant’s life, health or ability to regain maximum function. It includes a situation where, in the opinion of the treating Physician, the covered person may experience pain that cannot be adequately controlled while awaiting a standard internal Appeal decision. In these cases, the Claims Administrator will make a decision no later than seventy-two (72) hours of receipt of an Expedited Appeal request that meets the criteria for Expedited Appeal. An Expedited Appeal is a request concerning an Admission, availability of care, continued stay, or healthcare service for a covered person who is requesting Emergency services or has received Emergency services, but has not been discharged from a facility. Expedited Appeals are not provided for review of services previously rendered. An Expedited Appeal shall be made available to, and may be initiated by the covered person; the covered person’s authorized representative, or the Provider acting on behalf of the covered person. Requests for an expedited internal Appeal may be oral or written and should be made to: United Concordia Dental Appeals Division P.O. Box 69420 Harrisburg, PA 17106-9420 0-000-000-0000
