Common use of Formal Appeal of Adverse Benefit Determination Clause in Contracts

Formal Appeal of Adverse Benefit Determination. A Member who wishes to formally appeal an adverse benefits determination by BCI may do so through the following process: 1. An Insured may have an authorized representative pursue a benefit claim or an appeal of an Adverse Benefit Determination on their behalf. BCI requires that an Insured execute BCI’s “Appointment of Authorized Representative” form before BCI determines that an individual has been authorized to act on behalf of the Insured. The form can be found on BCI’s website at xxx.xxxxxxx.xxx. 2. A written appeal must be sent to the BCI Grievance and Appeals Specialist within one hundred eighty (180) days after receipt of the notice of Adverse Benefit Determination. The documents in support of such appeals may be submitted by phone or facsimile. The appeal should set forth the reasons why the Member contends BCI’s decision was incorrect. Any written comments, documents or other relevant information may be submitted with the appeal. 3. After receipt of the appeal, all facts, including those originally used in making the initial decision and any additional information that is sent or that is otherwise relevant, will be reviewed. BCI will mail a written reply to the Member within thirty (30) days after receipt of the written appeal. If the original decision is upheld, the reply will state the specific reasons for denial and the specific provisions on which the decision is based. Each appeal will be processed as quickly as possible. 4. Furthermore, the Member or their authorized representative has the right to reasonable access to, and copies of all documents, records, and other information that are relevant to the appeal. 5. If the original eligibility determination is upheld upon reconsideration, the Member may send an additional written appeal to the Appeals and Grievance Specialist requesting further review. This appeal must set forth the reasons for requesting additional reconsideration and must be sent within sixty (60) days of BCI’s mailing of the initial reconsideration decision. BCI will mail a written reply to the Member within thirty (30) days after receipt of the written appeal. A final decision on the appeal will be made within fifteen (15) days of its receipt.

Formal Appeal of Adverse Benefit Determination. A Member who wishes to formally appeal an adverse benefits determination by BCI may do so through the following process: 1. An Insured A Member may have an authorized representative pursue a benefit claim or an appeal of an Adverse Benefit Determination on their behalf. BCI requires that an Insured a Member execute BCI’s “Appointment of Authorized Representative” form before BCI determines that an individual has been authorized to act on behalf of the InsuredMember. The form can be found on BCI’s website Website at xxx.xxxxxxx.xxx. 2. A written appeal must be sent to the BCI Grievance and Appeals Specialist within one hundred eighty (180) days after receipt of the notice of Adverse Benefit Determination. The documents in support of such appeals may be submitted by phone or facsimile. The appeal should set forth the reasons why the Member contends BCI’s decision was incorrect. Any written comments, documents or other relevant information may be submitted with the appeal. 3. After receipt of the appeal, all facts, including those originally used in making the initial decision and any additional information that is sent or that is otherwise relevant, will be reviewed. BCI will mail a written reply to the Member within thirty (30) days after receipt of the written appeal. If the original decision is upheld, the reply will state the specific reasons for denial and the specific provisions on which the decision is based. Each appeal will be processed as quickly as possible. 4. Furthermore, the Member or their authorized representative has the right to reasonable access to, and copies of all documents, records, and other information that are relevant to the appeal. 5. If the original eligibility determination is upheld upon reconsideration, the Member may send an additional written appeal to the Appeals and Grievance Specialist requesting further review. This appeal must set forth the reasons for requesting additional reconsideration and must be sent within sixty (60) days of BCI’s mailing of the initial reconsideration decision. BCI will mail a written reply to the Member within thirty (30) days after receipt of the written appeal. A final decision on the appeal will be made within fifteen (15) days of its receipt.

Formal Appeal of Adverse Benefit Determination. A Member who wishes to formally appeal an adverse benefits determination by BCI may do so through the following process: 1. An Insured A Member may have an authorized representative pursue a benefit claim or an appeal of an Adverse Benefit Determination on their behalf. BCI requires that an Insured a Member execute BCI’s “Appointment of Authorized Representative” form before BCI determines that an individual has been authorized to act on behalf of the Insured. The form can be found on BCI’s website at xxx.xxxxxxx.xxx. 2. A written appeal must be sent to the BCI Grievance and Appeals Specialist within one hundred eighty (180) days after receipt of the notice of Adverse Benefit Determination. The documents in support of such appeals may be submitted by phone or facsimile. The appeal should set forth the reasons why the Member contends BCI’s decision was incorrect. Any written comments, documents or other relevant information may be submitted with the appeal. 3. After receipt of the appeal, all facts, including those originally used in making the initial decision and any additional information that is sent or that is otherwise relevant, will be reviewed. BCI will mail a written reply to the Member within thirty (30) days after receipt of the written appeal. If the original decision is upheld, the reply will state the specific reasons for denial and the specific provisions on which the decision is based. Each appeal will be processed as quickly as possible. 4. Furthermore, the Member or their authorized representative has the right to reasonable access to, and copies of all documents, records, and other information that are relevant to the appeal. 5. If the original eligibility determination is upheld upon reconsideration, the Member may send an additional written appeal to the Appeals and Grievance Specialist requesting further review. This appeal must set forth the reasons for requesting additional reconsideration and must be sent within sixty (60) days of BCI’s mailing of the initial reconsideration decision. BCI will mail a written reply to the Member within thirty (30) days after receipt of the written appeal. A final decision on the appeal will be made within fifteen (15) days of its receipt.