Initial Appeal. If the Member or the Member’s legal representative wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Member’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a...
Initial Appeal. A Party wishing to appeal the decision of the General Manager or Operating Board, as described above, must make written notice of appeal within five (5) business days after receipt of the General Manager’s or Operating Board’s written decision. The appeal will be addressed to the Vice Chairman of the Operating Board or, in the case of an appeal from a decision of the Operating Board, to the Governing Board, as provided below. The Vice Chair must schedule a meeting of the Operating Board within fifteen (15) business days of receipt of the notice and provide a written recommendation to the appropriate Parties within five (5) business days after the hearing. Any appeal of the recommendation of the Operating Board will be to the Governing Board.
Initial Appeal. 1. The appeal is checked initially to make sure that it was not the result of an error, and, if this was the case, the error is rectified, the individual informed, and the appeal closed.
Initial Appeal. A Party wishing to appeal the decision of the CECC Director, as described above, must make written notice of appeal within five (5) business days after receipt of the CECC Director’s written decision. The appeal will be addressed to the Chairman of the Advisory Board. The Chairman must schedule a meeting of the Advisory Board within fifteen (15) business days of receipt of the notice and provide a written recommendation to the appropriate Parties within five (5) business days after the hearing. Any appeal of the recommendation of the Advisory Board will be to the Executive Board.
Initial Appeal. If the Member wishes to appeal a GHC decision denying benefits, he/she must submit a request for an appeal either orally or in writing to GHC’s Member Appeal Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. Appeals should be directed to GHC’s Member Appeal Department, P.O. Box 34593, Seattle, WA 98124- 1593, toll free (000) 000-0000. An Appeal Coordinator will review initial appeal requests. GHC will then notify the Member of its determination or need for an extension of time within fourteen (14) days of receiving the request for appeal. Under no circumstances will the review timeframe exceed thirty (30) days without the Member’s written permission. There is an expedited appeals process in place for cases which meet criteria or where the Member’s provider believes that the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited appeal in writing to the above address, or by calling GHC’s Member Appeal Department toll free (000) 000-0000. The Member’s request for an expedited appeal will be processed and a decision issued no later than twenty-four
