Grievance Decision. If you have received an adverse decision, you, your representative, or your health care provider on your behalf, have the right to file a grievance with us. The following conditions apply to grievance filings: • The adverse decision grievance must be filed by you, your representative, or your health care provider on your behalf, with us within 180 calendar days of receipt of our adverse decision. • For prospective denials (denials on health services that have not yet been rendered), we will render a grievance decision in writing within 30 calendar days after the filing date, unless it involves an emergency case as explained below. The “filing date” is the earlier of five days after the date the grievance was mailed or the date of receipt. Unless written permission has been given, you, your representative, or your health care provider on your behalf, have the right to file a complaint with the Insurance Commissioner, if you have not received our grievance decision on or before the 30th calendar day after the filing date. • For retrospective denials (denials on health services that have already been rendered), we will render a grievance decision within 45 calendar days after the filing date. Unless written permission has been given, you, your representative, or your health care provider on your behalf, have the right to file a complaint with the Insurance Commissioner (see below), if you have not received our grievance decision on or before the 45th calendar day after the filing date. • With written permission from you, your representative, or your health care provider on your behalf, the time frame within which we must respond can be extended up to an additional 30 business days. • If we need additional information in order to review the case, we will notify you, your representative and/or your health care provider within five business days after the filing date. We will assist you, your representative, or the health care provider in gathering the necessary medical records without further delay. If no additional information is available or is not submitted to us, we will render a decision based on the available information. • Except as described under the first two bullets in the Complaints provision above, for retrospective denials, you, your representative, or your health care provider on your behalf, must file a grievance with us before filing a complaint with the Insurance Commissioner, as described below. • Notice of our grievance decision will be verbally communicated to you, your representative, or your health care provider. Written notification of our grievance decision will be sent to you, your representative and any health care provider who filed a grievance on your behalf within five business days after the grievance decision has been made. If we uphold the adverse determination, the denial notification will include a Notice of Grievance Decision. This Notice will include the appropriate information in the bulleted items under Adverse Decision above. This notice will also include a statement that the Health Advocacy Unit is available to assist you or your representative in filing a complaint with the Insurance Commissioner. • If any new or additional evidence is relied upon or generated by us during the determination of the grievance, we will provide it to you free of charge and sufficiently in advance of the due date of the response to the adverse benefit determination. • In addition to the first two bullets of the Complaints provision above, for prospective denials, you, your representative, or your health care provider on your behalf, may file an complaint with the Insurance Commissioner (see below) without first filing an grievance with us, if you, your representative, or your health care provider can demonstrate that the adverse decision concerns a compelling reason for which a delay would result in loss of life, serious impairment to a bodily function, serious dysfunction of a bodily organ, the Covered Person remaining seriously mentally ill or using intoxicating substances with symptoms that cause the Covered Person to be in danger to self or others or the Covered Person continues to experience severe withdrawal symptoms. In emergency cases, you, your representative or your health care provider on your behalf may request an expedited review of an adverse decision. An “emergency case” is a case involving an adverse decision of proposed health services which are necessary to treat a condition or illness that, without immediate medical attention, would seriously jeopardize the life or health of the Covered Person or his or her ability to regain maximum function, or would cause the Covered Person to be in danger to self or others, or cause the Covered Person to continue using intoxicating substances in an imminently dangerous manner. The procedure listed below will be followed: • If the health care provider filed the grievance, he or she will determine whether the basis for an emergency case or expedited review exists. If the Covered Person, or the Covered Person’s representative, filed the grievance, we, in consultation with the health care provider, will determine whether the basis for an emergency case or expedited review exists. In either case, the determination will be based on the above definition of “emergency case”. • We will render a verbal grievance decision to a grievance filed by you, your representative, or your health care provider on your behalf, within 24 hours of receipt of the grievance. Within one day after the verbal grievance decision has been communicated, we will send notice in writing of any grievance to you, your representative, and if applicable, your health care provider. If we need additional information in order to review the case, we will verbally inform you, your representative and/or your health care provider, and will assist with procuring the additional information. If we do not render a grievance decision within 24 hours, you, your representative, or your health care provider may file a complaint directly with the Insurance Commissioner. If we uphold our decision to deny coverage for the Covered Health Care Services, we will send you, your representative and/or your health care provider the grievance decision in writing within one day of the verbal notification. The Notice of Grievance Decision will include the appropriate information specified for the Notice of Adverse Decision above and will include that the Health Advocacy Unit is available to assist you or your representative in filing a complaint with the Insurance Commissioner.
Appears in 6 contracts
Samples: Individual Exchange Medical Policy, Individual Exchange Medical Policy, Individual Exchange Medical Policy
Grievance Decision. If you have received an adverse decision, you, your representative, or your health care provider on your behalf, have the right to file a grievance with us. The following conditions apply to grievance filings: • The adverse decision grievance must be filed by you, your representative, or your health care provider on your behalf, with us within 180 calendar days of receipt of our adverse decision. • For prospective denials (denials on health services that have not yet been rendered), we will render a grievance decision in writing within 30 calendar days after the filing date, unless it involves an emergency case as explained below. The “filing date” is the earlier of five days after the date the grievance was mailed or the date of receipt. Unless written permission has been given, you, your representative, or your health care provider on your behalf, have the right to file a complaint with the Insurance Commissioner, if you have not received our grievance decision on or before the 30th calendar day after the filing date. • For retrospective denials (denials on health services that have already been rendered), we will render a grievance decision within 45 calendar days after the filing date. Unless written permission has been given, you, your representative, or your health care provider on your behalf, have the right to file a complaint with the Insurance Commissioner (see below), if you have not received our grievance decision on or before the 45th calendar day after the filing date. • With written permission from you, your representative, or your health care provider on your behalf, the time frame within which we must respond can be extended up to an additional 30 business days. • If we need additional information in order to review the case, we will notify you, your representative and/or your health care provider within five business days after the filing date. We will assist you, your representative, or the health care provider in gathering the necessary medical records without further delay. If no additional information is available or is not submitted to us, we will render a decision based on the available information. • Except as described under the first two bullets in the Complaints provision above, for retrospective denials, you, your representative, or your health care provider on your behalf, must file a grievance with us before filing a complaint with the Insurance Commissioner, as described below. • Notice of our grievance decision will be verbally communicated to you, your representative, or your health care provider. Written notification of our grievance decision will be sent to you, your representative and any health care provider who filed a grievance on your behalf within five business days after the grievance decision has been made. If we uphold the adverse determination, the denial notification will include a Notice of Grievance Decision. This Notice will include the appropriate information in the bulleted items under Adverse Decision above. This notice will also include a statement that the Health Advocacy Unit is available to assist you or your representative in filing a complaint with the Insurance Commissioner. • If any new or additional evidence is relied upon or generated by us during the determination of the grievance, we will provide it to you free of charge and sufficiently in advance of the due date of the response to the adverse benefit determination. • In addition to the first two bullets of the Complaints provision above, for prospective denials, you, your representative, or your health care provider on your behalf, may file an complaint with the Insurance Commissioner (see below) without first filing an grievance with us, if you, your representative, or your health care provider can demonstrate that the adverse decision concerns a compelling reason for which a delay would result in loss of life, serious impairment to a bodily function, serious dysfunction of a bodily organ, the Covered Person remaining seriously mentally ill or using intoxicating substances with symptoms that cause the Covered Person to be in danger to self or others or the Covered Person continues to experience severe withdrawal symptoms. In emergency cases, you, your representative or your health care provider on your behalf may request an expedited review of an adverse decision. An “emergency case” is a case involving an adverse decision of proposed health services which are necessary to treat a condition or illness that, without immediate medical attention, would seriously jeopardize the life or health of the Covered Person or his or her ability to regain maximum function, or would cause the Covered Person to be in danger to self or others, or cause the Covered Person to continue using intoxicating substances in an imminently dangerous manner. The procedure listed below will be followed: • If the health care provider filed the grievance, he or she will determine whether the basis for an emergency case or expedited review exists. If the Covered Person, or the Covered Person’s representative, filed the grievance, we, in consultation with the health care provider, will determine whether the basis for an emergency case or expedited review exists. In either case, the determination will be based on the above definition of “emergency case”. • We will render a verbal grievance decision to a grievance filed by you, your representative, or your health care provider on your behalf, within 24 hours of receipt of the grievance. Within one day after the verbal grievance decision has been communicated, we will send notice in writing of any grievance to you, your representative, and if applicable, your health care provider. If we need additional information in order to review the case, we will verbally inform you, your representative and/or your health care provider, and will assist with procuring the additional information. If we do not render a grievance decision within 24 hours, you, your representative, or your health care provider may file a complaint directly with the Insurance Commissioner. If we uphold our decision to deny coverage for the Covered Health Care Services, we will send you, your representative and/or your health care provider the grievance decision in writing within one day of the verbal notification. The Notice of Grievance Decision will include the appropriate information specified for the Notice of Adverse Decision above and will include that the Health Advocacy Unit is available to assist you or your representative in filing a complaint with the Insurance Commissioner.
Appears in 1 contract
Samples: Individual Exchange Medical Policy
Grievance Decision. If you have received an adverse decision, you, your representative, or your health care provider on your behalf, have the right to file a grievance with us. The following conditions apply to grievance filings: • The adverse decision grievance must be filed by you, your representative, or your health care provider on your behalf, with us within 180 calendar days of receipt of our adverse decision. • For prospective denials (denials on health services that have not yet been rendered), we will render a grievance decision in writing within 30 calendar days after the filing date, unless it involves an emergency case as explained below. The “filing date” is the earlier of five days after the date the grievance was mailed or the date of receipt. Unless written permission has been given, you, your representative, or your health care provider on your behalf, have the right to file a complaint with the Insurance Commissioner, if you have not received our grievance decision on or before the 30th calendar day after the filing date. • For retrospective denials (denials on health services that have already been rendered), we will render a grievance decision within 45 calendar days after the filing date. Unless written permission has been given, you, your representative, or your health care provider on your behalf, have the right to file a complaint with the Insurance Commissioner (see below), if you have not received our grievance decision on or before the 45th calendar day after the filing date. • With written permission from you, your representative, or your health care provider on your behalf, the time frame within which we must respond can be extended up to an additional 30 business days. • If we need additional information in order to review the case, we will notify you, your representative and/or your health care provider within five business days after the filing date. We will assist you, your representative, or the health care provider in gathering the necessary medical records without further delay. If no additional information is available or is not submitted to us, we will render a decision based on the available information. • Except as described under the first two bullets in the Complaints provision above, for retrospective denials, you, your representative, or your health care provider on your behalf, must file a grievance with us before filing a complaint with the Insurance Commissioner, as described below. • Notice of our grievance decision will be verbally communicated to you, your representative, or your health care provider. Written notification of our grievance decision will be sent to you, your representative and any health care provider who filed a grievance on your behalf within five business days after the grievance decision has been made. If we uphold the adverse determination, the denial notification will include a Notice of Grievance Decision. This Notice will include the appropriate information in the bulleted items under Adverse Decision above. This notice will also include a statement that the Health Advocacy Unit is available to assist you or your representative in filing a complaint with the Insurance Commissioner. • If any new or additional evidence is relied upon or generated by us during the determination of the grievance, we will provide it to you free of charge and sufficiently in advance of the due date of the response to the adverse benefit determination. • In addition to the first two bullets of the Complaints provision above, for prospective denials, you, your representative, or your health care provider on your behalf, may file an complaint with the Insurance Commissioner (see below) without first filing an grievance with us, if you, your representative, or your health care provider can demonstrate that the adverse decision concerns a compelling reason for which a delay would result in loss of life, serious impairment to a bodily function, serious dysfunction of a bodily organ, the Covered Person remaining seriously mentally ill or using intoxicating substances with symptoms that cause the Covered Person to be in danger to self or others or the Covered Person continues to experience severe withdrawal symptoms. In emergency cases, you, your representative or your health care provider on your behalf may request an expedited review of an adverse decision. An “emergency case” is a case involving an adverse decision of proposed health services which are necessary to treat a condition or illness that, without immediate medical attention, would seriously jeopardize the life or health of the Covered Person or his or her ability to regain maximum function, or would cause the Covered Person to be in danger to self or others, or cause the Covered Person to continue using intoxicating substances in an imminently dangerous manner. The procedure listed below will be followed: SAMPLE • If the health care provider filed the grievance, he or she will determine whether the basis for an emergency case or expedited review exists. If the Covered Person, or the Covered Person’s representative, filed the grievance, we, in consultation with the health care provider, will determine whether the basis for an emergency case or expedited review exists. In either case, the determination will be based on the above definition of “emergency case”. • We will render a verbal grievance decision to a grievance filed by you, your representative, or your health care provider on your behalf, within 24 hours of receipt of the grievance. Within one day after the verbal grievance decision has been communicated, we will send notice in writing of any grievance to you, your representative, and if applicable, your health care provider. If we need additional information in order to review the case, we will verbally inform you, your representative and/or your health care provider, and will assist with procuring the additional information. If we do not render a grievance decision within 24 hours, you, your representative, or your health care provider may file a complaint directly with the Insurance Commissioner. If we uphold our decision to deny coverage for the Covered Health Care Services, we will send you, your representative and/or your health care provider the grievance decision in writing within one day of the verbal notification. The Notice of Grievance Decision will include the appropriate information specified for the Notice of Adverse Decision above and will include that the Health Advocacy Unit is available to assist you or your representative in filing a complaint with the Insurance Commissioner.
Appears in 1 contract
Samples: Individual Exchange Medical Policy
