Common use of Expedited Appeals Clause in Contracts

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, or your written request for a plan appeal and any health information to us by sending a letter to: Ambetter from Sunshine Health Grievance and Appeal Coordinator 0000 Xxxxxxxxxxxxx Xxxxxxx, Xxxxx 000 Sunrise, FL 33323 Fax: 000-000-0000 If the Notice of Action that you were sent said that we were terminating, suspending, or reducing a service that you were getting as an Ambetter from Sunshine Health member, you have the right to keep getting the service. If you let us know that you want to continue the service within ten (10) days of the Notice of Action letter, we will approve you to continue this service until the plan appeal decision is made. To do this, Ambetter from Sunshine Health must have been approving you to get the service before, the services were ordered by an authorized provider, and the time of the approval for that service has not ended. If after the review of your plan appeal Ambetter from Sunshine Health decides that the decision to terminate, suspend, or reduce the service was right and you kept getting the service, you may have to pay for the service. You may request these documents by contacting: Ambetter from Sunshine Health Grievance and Appeal Coordinator 0000 Xxxxxxxxxxxxx Xxxxxxx, Xxxxx 000 Sunrise, FL 33323 Phone: 000-000-0000 Fax: 000-000-0000 TTY/TDD: 000-000-0000 Xxxxxxxx_Xxxxxxx@xxxxxxx.xxx If you have questions, call us at 000-000-0000 or TDD/TTY at 000-000-0000.

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 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 (Relay FL 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 0-000-000-0000 or TTY/TDD Relay FL 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, or your written request for a plan appeal and any health information to us by sending a letter to: Ambetter from Sunshine Health Grievance and Appeal Coordinator 0000 Xxxxxxxxxxxxx Xxxxxxx, Xxxxx 000 Sunrise, FL 33323 Fax: 000-000-0000 If the Notice of Action that you were sent said that we were terminating, suspending, or reducing a service that you were getting as an Ambetter from Sunshine Health member, you have the right to keep getting the service. If you let us know that you want to continue the service within ten (10) days of the Notice of Action letter, we will approve you to continue this service until the plan appeal decision is made. To do this, Ambetter from Sunshine Health must have been approving you to get the service before, the services were ordered by an authorized provider, and the time of the approval for that service has not ended. If after the review of your plan appeal Ambetter from Sunshine Health decides that the decision to terminate, suspend, or reduce the service was right and you kept getting the service, you may have to pay for the service. You may request these documents by contacting: Ambetter from Sunshine Health Grievance and Appeal Coordinator 0000 Xxxxxxxxxxxxx Xxxxxxx, Xxxxx 000 Sunrise, FL 33323 Phone: 0-000-000-0000 Fax: 000-000-0000 TTY/TDD: Relay FL 000-000-0000 Xxxxxxxx_Xxxxxxx@xxxxxxx.xxx If you have questions, call us at 0-000-000-0000 or TDD/TTY Relay FL at 000-000-0000. External Review: If you are dissatisfied with the Ambetter from Sunshine Health appeal decision, you have the right to have an independent review of certain final decisions made by Ambetter from Sunshine Health. Ambetter from Sunshine Health must pay the cost of the Independent Review Organization (IRO) conducting the external review. If you request it, an appeal will be conducted by an external review organization called an IRO. An IRO is not connected in any way with Ambetter from Sunshine Health. Ambetter from Sunshine Health must abide by the IRO’s decision and carry out its instructions. You can make a request for external review in writing to Ambetter from Sunshine Health Plan at: Ambetter from Sunshine Health Appeals Department 0000 Xxxxxxxxxxxxx Xxxxxxx Sunrise, FL 33323 If assistance is needed with completing the written request, you may contact Ambetter from Sunshine Health at: Phone 0-000-000-0000 Relay FL 000-000-0000 Fax 0-000-000-0000 We will send your request to the IRO. You must contact the IRO or us within 120 calendar days (4 months) of the date of your appeal resolution letter. If you do not file your appeal for an external independent review within 120 days, it cannot be reviewed. If you are not sure whether your appeal is eligible, or if you want more information, please contact Ambetter from Sunshine Health. You, or someone you authorized to do so, shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits. All comments, documents, records and other information submitted by the claimant relating to the claim for benefits, regardless of whether such information was submitted or considered in the initial adverse benefit determination, will be considered in the internal appeal. External Review Ambetter from Sunshine Health members are offered two levels of appeal for adverse benefit determinations related to a service that requires medical review. An external review decision is binding on us. An external review decision is binding on the claimant except to the extent the claimant has other remedies available under applicable federal or state law. We will pay for the costs of the external review performed by the independent reviewer.

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, or your written request for a plan appeal and any health information to us by sending a letter to: Ambetter from Sunshine Health Grievance and Appeal Coordinator 0000 Xxxxxxxxxxxxx Xxxxxxx, Xxxxx 000 Sunrise, FL 33323 Fax: 000-000-0000 If the Notice of Action that you were sent said that we were terminating, suspending, or reducing a service that you were getting as an Ambetter from Sunshine Health member, you have the right to keep getting the service. If you let us know that you want to continue the service within ten (10) days of the Notice of Action letter, we will approve you to continue this service until the plan appeal decision is made. To do this, Ambetter from Sunshine Health must have been approving you to get the service before, the services were ordered by an authorized provider, and the time of the approval for that service has not ended. If after the review of your plan appeal Ambetter from Sunshine Health decides that the decision to terminate, suspend, or reduce the service was right and you kept getting the service, you may have to pay for the service. You may request these documents by contacting: Ambetter from Sunshine Health Grievance and Appeal Coordinator 0000 Xxxxxxxxxxxxx Xxxxxxx, Xxxxx 000 Sunrise, FL 33323 Phone: 000-000-0000 Fax: 000-000-0000 TTY/TDD: 000-000-0000 Xxxxxxxx_Xxxxxxx@xxxxxxx.xxx If you have questions, call us at 000-000-0000 or TDD/TTY at 000-000-0000.. External Review If you are dissatisfied with the Ambetter from Sunshine Health appeal decision, you have the right to have an independent review of certain final decisions made by Ambetter from Sunshine Health. Ambetter from Sunshine Health members are offered two levels of appeal for adverse benefit determinations related to a service that requires medical review. An external review decision is binding on us. An external review decision is binding on the claimant except to the extent the claimant has other remedies available under applicable federal or state law. We will pay for the costs of the external review performed by the independent reviewer. You can make a request for external review in writing to Ambetter from Sunshine Health Plan at: Ambetter from Sunshine Health Appeals Department 0000 Xxxxxxxxxxxxx Xxxxxxx Sunrise, FL 33323 If assistance is needed with completing the written request, you may contact Ambetter from Sunshine Health at: Phone 000-000-0000 TTY/TDD 000-000-0000 Fax 0-000-000-0000 Applicability/Eligibility The external review procedures apply to any hospital or medical policy or certificate; excluding accident only or disability income only insurance. External review is available for grievances that involve:

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 (Relay FL 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 0-000-000-0000 or TTY/TDD Relay FL 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, or your written request for a plan appeal and any health information to us by sending a letter to: Ambetter from Sunshine Health Grievance and Appeal Coordinator 0000 Xxxxxxxxxxxxx Xxxxxxx, Xxxxx 000 Sunrise, FL 33323 Fax: 000-000-0000 If the Notice of Action that you were sent said that we were terminating, suspending, or reducing a service that you were getting as an Ambetter from Sunshine Health member, you have the right to keep getting the service. If you let us know that you want to continue the service within ten (10) days of the Notice of Action letter, we will approve you to continue this service until the plan appeal decision is made. To do this, Ambetter from Sunshine Health must have been approving you to get the service before, the services were ordered by an authorized provider, and the time of the approval for that service has not ended. If after the review of your plan appeal Ambetter from Sunshine Health decides that the decision to terminate, suspend, or reduce the service was right and you kept getting the service, you may have to pay for the service. You may request these documents by contacting: Ambetter from Sunshine Health Grievance and Appeal Coordinator 0000 Xxxxxxxxxxxxx Xxxxxxx, Xxxxx 000 Sunrise, FL 33323 Phone: 0-000-000-0000 Fax: 000-000-0000 TTY/TDD: Relay FL 000-000-0000 Xxxxxxxx_Xxxxxxx@xxxxxxx.xxx If you have questions, call us at 0-000-000-0000 or TDD/TTY Relay FL at 000-000-0000. External Review If you are dissatisfied with the Ambetter from Sunshine Health appeal decision, you have the right to have an independent review of certain final decisions made by Ambetter from Sunshine Health. Ambetter from Sunshine Health must pay the cost of the Independent Review Organization (IRO)) conducting the external review. If you request it, an appeal will be conducted by an external review organization called an IRO. An IRO is not connected in any way with Ambetter from Sunshine Health. Ambetter from Sunshine Health must abide by the IRO’s decision and carry out its instructions. You can make a request for external review in writing to Ambetter from Sunshine Health Plan at: Ambetter from Sunshine Health Appeals Department 0000 Xxxxxxxxxxxxx Xxxxxxx Sunrise, FL 33323 If assistance is needed with completing the written request, you may contact Ambetter from Sunshine Health at: Phone 0-000-000-0000 Relay FL 000-000-0000 Fax 0-000-000-0000 We will send your request to the IRO. You must contact the IRO or us within 120 calendar days (4 months) of the date of your appeal resolution letter. If you do not file your appeal for an external independent review within 120 days, it cannot be reviewed. If you are not sure whether your appeal is eligible, or if you want more information, please contact Ambetter from Sunshine Health. You, or someone you authorized to do so, shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits. All comments, documents, records and other information submitted by the claimant relating to the claim for benefits, regardless of whether such information was submitted or considered in the initial adverse benefit determination, will be considered in the internal appeal. External Review Ambetter from Sunshine Health members are offered two levels of appeal for adverse benefit determinations related to a service that requires medical review. An external review decision is binding on us. An external review decision is binding on the claimant except to the extent the claimant has other remedies available under applicable federal or state law. We will pay for the costs of the external review performed by the independent reviewer.