Health Options’ Internal Appeal Process. Health Options will provide you with an Appeal process that is a full and fair review. Health Options will ensure the following: a. The person(s) reviewing your Appeal will not be the same persons making the initial Claim Denial, and will not be subordinate to or supervised by the person making the initial Claim Denial; b. If your Level I Appeal involves a Medical Necessity determination, at least one person reviewing your Appeal will be an appropriate medical professional with experience or training in the medical specialty involved; c. You will have 180 days after receiving a Claim Denial to file an Appeal; d. You will have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those materials or information were considered in the initial Claim Denial; e. You will be provided upon request, at no cost, reasonable access to, and copies of, all documents, records, and other information relevant to or considered in making the initial Claim Denial; f. The Appeal will be a “de novo” proceeding. This means that the reviewers will make the Appeal decision without considering or relying upon the initial Claim Denial; and g. If the Appeal involves a Claim Denial based in some manner on medical judgment: i. The Level I Appeal will be conducted by or in consultation with a medical professional with experience or training in the relevant medical specialty; ii. The Appeal decision will include the title and qualifying credentials of the person conducting the review; and iii. You will be provided with the identity and qualifications of any medical or vocational expert whose advice was considered, whether or not it was used in making the initial Claim Denial. Your Appeal rights include: a. Being allowed to review the claim file and to present evidence and testimony as part of the Appeals process; b. Being given, free of charge, any new or additional evidence considered, relied upon, or generated by Health Options (or at the direction of Health Options) in connection with the claim, unless the evidence is confidential or privileged. Health Options will give you the evidence as soon as possible and with enough time in advance of the decision to give you a reasonable opportunity to respond; c. Before Health Options can issue a final adverse determination based on a new or additional reason, being provided with the reason, free of charge, with enough time in advance of the decision to give you a reasonable opportunity to respond; and d. Receiving a notice from Health Options describing your Appeal rights within three business days after Health Options receives your Appeal. The remainder of this section describes Health Options’ internal Appeal process. If you receive an Adverse Benefit Determination, Adverse Health Care Treatment Decision, or Adverse Benefit Determination not involving a Health Care Treatment Decision, you may file an Appeal. Your Appeal will be decided by one or more persons not involved in making the decision that you are Appealing. You may have a Designee or your Provider assist you with your Appeal. Please follow the steps described below. Members who are visually and/or hearing impaired may request complaint and Appeal process materials in an appropriately accessible format by contacting Health Options Member Services at 1-855-624-6463 (TTY/TDD: 711). If you have special cultural needs or require translation services, please contact Member Services at 0-000-000-0000.
Appears in 3 contracts
Samples: Member Benefit Agreement, Member Benefit Agreement, Member Benefit Agreement
Health Options’ Internal Appeal Process. Health Options will provide you with an Appeal process that is a full and fair review. Health Options will ensure the following:
a. 1. The person(s) reviewing your Appeal will not be the same persons making the initial Claim Denial, and will not be subordinate to or supervised by the person making the initial Claim Denial;
b. 2. If your Level I Appeal involves a Medical Necessity determination, at least one person reviewing your Appeal will be an appropriate medical professional with experience the same or training similar medical specialty as involved in the medical specialty involvedAppeal;
c. 3. You will have 180 days after receiving a Claim Denial to file an Appeal;
d. 4. You will have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those materials or information were considered in the initial Claim Denial;
e. 5. You will be provided upon request, at no cost, reasonable access to, and copies of, all documents, records, and other information relevant to or considered in making the initial Claim Denial;
f. 6. The Appeal will be a “de novo” proceeding. This means that the reviewers will make the Appeal decision without considering or relying upon the initial Claim Denial; and
g. 7. If the Appeal involves a Claim Denial based in some manner on medical judgment:
i. The Level I Appeal will be conducted by or in consultation with a medical professional with experience or training in the relevant same or similar medical specialtyspecialty as the appealed service;
ii. The Appeal decision will include the title and qualifying credentials of the person conducting the review; and
iii. You will be provided with the identity and qualifications of any medical or vocational expert whose advice was considered, whether or not it was used in making the initial Claim Denial. Your Appeal rights include:
a. 1. Being allowed to review the claim file and to present evidence and testimony as part of the Appeals process;
b. 2. Being given, free of charge, any new or additional evidence considered, relied upon, or generated by Health Options (or at the direction of Health Options) in connection with the claim, unless the evidence is confidential or privileged. Health Options will give you the evidence as soon as possible and with enough time in advance of the decision to give you a reasonable opportunity to respond;
c. Before Health Options can issue a final adverse determination based on a new or additional reason, being provided with the reason, free of charge, with enough time in advance of the decision to give you a reasonable opportunity to respond; and
d. Receiving a notice from Health Options describing your Appeal rights within three business days after Health Options receives your Appeal. The remainder of this section describes Health Options’ internal Appeal process. If you receive an Adverse Benefit Determination, Adverse Health Care Treatment Decision, or Adverse Benefit Determination not involving a Health Care Treatment Decision, you may file an Appeal. Your Appeal will be decided by one or more persons not involved in making the decision that you are Appealing. You may have a Designee or your Provider assist you with your Appeal. Please follow the steps described below. Members who are visually and/or hearing impaired may request complaint and Appeal process materials in an appropriately accessible format by contacting Health Options Member Services at 1-855-624-6463 (TTY/TDD: 711). If you have special cultural needs or require translation services, please contact Member Services at 0-000-000-0000.
Appears in 1 contract
Samples: Member Benefit Agreement
Health Options’ Internal Appeal Process. Health Options will provide you with an Appeal process that is a full and fair review. Health Options will ensure the following:
a. The person(s) reviewing your Appeal will not be the same persons making the initial Claim Denial, and will not be subordinate to or supervised by the person making the initial Claim Denial;
b. If your Level I Appeal involves a Medical Necessity determination, at least one person reviewing your Appeal will be an appropriate medical professional with experience the same or training similar medical specialty as involved in the medical specialty involvedAppeal;
c. You will have 180 days after receiving a Claim Denial to file an Appeal;
d. You will have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those materials or information were considered in the initial Claim Denial;
e. You will be provided upon request, at no cost, reasonable access to, and copies of, all documents, records, and other information relevant to or considered in making the initial Claim Denial;
f. The Appeal will be a “de novo” proceeding. This means that the reviewers will make the Appeal decision without considering or relying upon the initial Claim Denial; and
g. If the Appeal involves a Claim Denial based in some manner on medical judgment:
i. The Level I Appeal will be conducted by or in consultation with a medical professional with experience or training in the relevant same or similar medical specialtyspecialty as the appealed service;
ii. The Appeal decision will include the title and qualifying credentials of the person conducting the review; and
iii. You will be provided with the identity and qualifications of any medical or vocational expert whose advice was considered, whether or not it was used in making the initial Claim Denial. SAMPLE Your Appeal rights include:
a. Being allowed to review the claim file and to present evidence and testimony as part of the Appeals process;
b. Being given, free of charge, any new or additional evidence considered, relied upon, or generated by Health Options (or at the direction of Health Options) in connection with the claim, unless the evidence is confidential or privileged. Health Options will give you the evidence as soon as possible and with enough time in advance of the decision to give you a reasonable opportunity to respond;
c. Before Health Options can issue a final adverse determination based on a new or additional reason, being provided with the reason, free of charge, with enough time in advance of the decision to give you a reasonable opportunity to respond; and
d. Receiving a notice from Health Options describing your Appeal rights within three business days after Health Options receives your Appeal. The remainder of this section describes Health Options’ internal Appeal process. If you receive an Adverse Benefit Determination, Adverse Health Care Treatment Decision, or Adverse Benefit Determination not involving a Health Care Treatment Decision, you may file an Appeal. Your Appeal will be decided by one or more persons not involved in making the decision that you are Appealing. You may have a Designee or your Provider assist you with your Appeal. Please follow the steps described below. Members who are visually and/or hearing impaired may request complaint and Appeal process materials in an appropriately accessible format by contacting Health Options Member Services at 1-855-624-6463 (TTY/TDD: 711). If you have special cultural needs or require translation services, please contact Member Services at 0-0- 000-000-0000.
Appears in 1 contract
Samples: Member Benefit Agreement
Health Options’ Internal Appeal Process. Health Options will provide you with an Appeal process that is a full and fair review. Health Options will ensure the following:
a. 1. The person(s) reviewing your Appeal will not be the same persons making the initial Claim Denial, and will not be subordinate to or supervised by the person making the initial Claim Denial;
b. 2. If your Level I Appeal involves a Medical Necessity determination, at least one person reviewing your Appeal will be an appropriate medical professional with experience or training in the medical specialty involved;
c. 3. You will have 180 days after receiving a Claim Denial to file an Appeal;
d. 4. You will have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those materials or information were considered in the initial Claim Denial;
e. 5. You will be provided upon request, at no cost, reasonable access to, and copies of, all documents, records, and other information relevant to or considered in making the initial Claim Denial;
f. 6. The Appeal will be a “de novo” proceeding. This means that the reviewers will make the Appeal decision without considering or relying upon the initial Claim Denial; and
g. 7. If the Appeal involves a Claim Denial based in some manner on medical judgment:
i. The Level I Appeal will be conducted by or in consultation with a medical professional with experience or training in the relevant medical specialty;
ii. The Appeal decision will include the title and qualifying credentials of the person conducting the review; and
iii. You will be provided with the identity and qualifications of any medical or vocational expert whose advice was considered, whether or not it was used in making the initial Claim Denial. Your Appeal rights include:
a. 1. Being allowed to review the claim file and to present evidence and testimony as part of the Appeals process;
b. 2. Being given, free of charge, any new or additional evidence considered, relied upon, or generated by Health Options (or at the direction of Health Options) in connection with the claim, unless the evidence is confidential or privileged. Health Options will give you the evidence as soon as possible and with enough time in advance of the decision to give you a reasonable opportunity to respond;
c. Before Health Options can issue a final adverse determination based on a new or additional reason, being provided with the reason, free of charge, with enough time in advance of the decision to give you a reasonable opportunity to respond; and
d. Receiving a notice from Health Options describing your Appeal rights within three business days after Health Options receives your Appeal. The remainder of this section describes Health Options’ internal Appeal process. If you receive an Adverse Benefit Determination, Adverse Health Care Treatment Decision, or Adverse Benefit Determination not involving a Health Care Treatment Decision, you may file an Appeal. Your Appeal will be decided by one or more persons not involved in making the decision that you are Appealing. You may have a Designee or your Provider assist you with your Appeal. Please follow the steps described below. Members who are visually and/or hearing impaired may request complaint and Appeal process materials in an appropriately accessible format by contacting Health Options Member Services at 1-855-624-6463 (TTY/TDD: 711). If you have special cultural needs or require translation services, please contact Member Services at 0-000-000-0000.
Appears in 1 contract
Samples: Member Benefit Agreement
Health Options’ Internal Appeal Process. Health Options will provide you with an Appeal process that is a full and fair review. Health Options will ensure the following:
a. The person(s) reviewing your Appeal will not be the same persons making the initial Claim Denial, and will not be subordinate to or supervised by the person making the initial Claim Denial;
b. If your Level I Appeal involves a Medical Necessity determination, at least one person reviewing your Appeal will be an appropriate medical professional with experience or training in the same or similar medical specialty involvedas involved in the Appeal;
c. You will have 180 days after receiving a Claim Denial to file an Appeal;
d. You will have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those materials or information were considered in the initial Claim Denial;
e. You will be provided upon request, at no cost, reasonable access to, and copies of, all documents, records, and other information relevant to or considered in making the initial Claim Denial;
f. The Appeal will be a “de novo” proceeding. This means that the reviewers will make the Appeal decision without considering or relying upon the initial Claim Denial; and
g. If the Appeal involves a Claim Denial based in some manner on medical judgment:
i. The Level I Appeal will be conducted by or in consultation with a medical professional with experience or training in the relevant same or similar medical specialtyspecialty as the appealed service;
ii. The Appeal decision will include the title and qualifying credentials of the person conducting the review; and
iii. You will be provided with the identity and qualifications of any medical or vocational expert whose advice was considered, whether or not it was used in making the initial Claim Denial. Your Appeal rights include:
a. Being allowed to review the claim file and to present evidence and testimony as part of the Appeals process;
b. Being given, free of charge, any new or additional evidence considered, relied upon, or generated by Health Options (or at the direction of Health Options) in connection with the claim, unless the evidence is confidential or privileged. Health Options will give you the evidence as soon as possible and with enough time in advance of the decision to give you a reasonable opportunity to respond;
c. Before Health Options can issue a final adverse determination based on a new or additional reason, being provided with the reason, free of charge, with enough time in advance of the decision to give you a reasonable opportunity to respond; and
d. Receiving a notice from Health Options describing your Appeal rights within three business days after Health Options receives your Appeal. The remainder of this section describes Health Options’ internal Appeal process. If you receive an Adverse Benefit Determination, Adverse Health Care Treatment Decision, or Adverse Benefit Determination not involving a Health Care Treatment Decision, you may file an Appeal. Your Appeal will be decided by one or more persons not involved in making the decision that you are Appealing. You may have a Designee or your Provider assist you with your Appeal. Please follow the steps described below. Members who are visually and/or hearing impaired may request complaint and Appeal process materials in an appropriately accessible format by contacting Health Options Member Services at 1-855-624-6463 (TTY/TDD: 711). If you have special cultural needs or require translation services, please contact Member Services at 0-000-000-0000.
Appears in 1 contract
Samples: Member Benefit Agreement
