Common use of Internal Appeal Process Clause in Contracts

Internal Appeal Process. a. The Plan maintains an internal appeal process involving one (1) level of review. b. At any time during the appeal process, a Member may choose to designate an authorized representative to participate in the appeal process on his/her behalf. The Member or the Member’s authorized representative shall notify the Plan, in writing, of the designation. For purposes of the appeal process, Member includes designees, legal representatives and, in the case of a minor, parents of a Member entitled or authorized to act on the Member’s behalf. The Plan reserves the right to establish reasonable procedures for determining whether an individual has been authorized to act on behalf of a Member. Such procedures as adopted by the Plan shall, in the case of an Urgent Care Claim, permit a Professional Provider with knowledge of the Member’s medical condition to act as the Member’s authorized representative. At any time during the appeal process, a Member may contact the Member Service Department at the toll-free telephone number listed on his/her Identification Card to inquire about the filing or status of an appeal. c. If a Member has received notification that a Claim has been denied by the Plan, in whole or in part, the Member may appeal the decision. For purposes of this Subsection, determinations made by the Plan to rescind a Member’s coverage, or to deny the enrollment request of an individual that the Plan has determined is ineligible for coverage under this Agreement, can also be appealed in accordance with the procedures set forth in this Subsection. The Member’s appeal must be submitted within one hundred eighty (180) days from the date of the Member’s receipt of notification of the adverse decision. d. The Member, upon request to the Plan, may review all documents, records and other information relevant to the appeal and shall have the right to submit or present additional evidence or testimony which includes any written or oral statements, comments and/or remarks, documents, records, information, data or other material in support of the appeal. e. The appeal will be reviewed by a representative from the Member Grievance and Appeals Department. The representative shall not have been involved or be the subordinate of any individual that was involved in any previous decision to deny the Claim or matter which is the subject of the Member’s appeal. In rendering a decision on the appeal, the Member Grievance and Appeals Department will take into account all evidence, comments, testimony, documents, records and other information submitted by the Member without regard to whether such information was previously submitted to or considered by the Plan. The Member Xxxxxxxxx and Appeals Department will afford no deference to any prior adverse decision on the Claim which is the subject of the appeal. f. Each appeal will be promptly investigated and the Plan will provide written notification of its decision within the following time frames: i) When the appeal involves a non-urgent care Pre-service Claim, within a reasonable period of time appropriate to the medical circumstances involved not to exceed thirty (30) days following receipt of the appeal; ii) When the appeal involves an Urgent Care Claim, as soon as possible taking into account the medical exigencies involved but not later than seventy-two (72) hours following receipt of the appeal; or iii) When the appeal involves a Post-service Claim, or a decision by the Plan to rescind coverage or deny an enrollment request because the individual is not eligible for coverage, within a reasonable period of time not to exceed thirty (30) days following receipt of the appeal. g. If the Plan fails to provide notice of its decision within the above-stated time frames or otherwise fails to strictly adhere to these appeal procedures, the Member may be permitted to request an external review and/or pursue any applicable right to arbitration. h. In the event that the Plan renders an adverse decision on the internal appeal, the notification shall include, among other items, the specific reason or reasons for the adverse decision and a statement regarding the right of the Member to request an external review and/or pursue any applicable right to arbitration.

Internal Appeal Process. a. The Plan maintains an internal appeal process involving one (1) level of review. b. At any time during the appeal process, a Member may choose to designate an authorized representative to participate in the appeal process on his/her behalf. The Member or the Member’s authorized representative shall notify the Plan, in writing, of the designation. For purposes of the appeal process, Member includes designees, legal representatives and, in the case of a minor, parents of a Member entitled or authorized to act on the Member’s behalf. The Plan reserves the right to establish reasonable procedures for determining whether an individual has been authorized to act on behalf of a Member. Such procedures as adopted by the Plan shall, in the case of an Urgent Care Claim, permit a Professional Provider with knowledge of the Member’s medical condition to act as the Member’s authorized representative. At any time during the appeal process, a Member may contact the Member Service Department at the toll-free telephone number listed on his/her Identification Card to inquire about the filing or status of an appeal. c. If a Member has received notification that a Claim has been denied by the Plan, in whole or in part, the Member may appeal the decision. For purposes of this Subsection, determinations made by the Plan to rescind a Member’s coverage, or to deny the enrollment request of an individual that the Plan has determined is ineligible for coverage under this Agreement, can also be appealed in accordance with the procedures set forth in this Subsection. The Member’s appeal must be submitted within one hundred eighty (180) days from the date of the Member’s receipt of notification of the adverse decision. d. The Member, upon request to the Plan, may review all documents, records and other information relevant to the appeal and shall have the right to submit or present additional evidence or testimony which includes any written or oral statements, comments and/or remarks, documents, records, information, data or other material in support of the appeal. e. The appeal will be reviewed by a representative from the Member Grievance and Appeals Department. The representative shall not have been involved or be the subordinate of any individual that was involved in any previous decision to deny the Claim or matter which is the subject of the Member’s appeal. In rendering a decision on the appeal, the Member Grievance and Appeals Department will take into account all evidence, comments, testimony, documents, records and other information submitted by the Member without regard to whether such information was previously submitted to or considered by the Plan. The Member Xxxxxxxxx Grievance and Appeals Department will afford no deference to any prior adverse decision on the Claim which is the subject of the appeal. f. Each appeal will be promptly investigated and the Plan will provide written notification of its decision within the following time frames: i) When the appeal involves a non-urgent care Pre-service Claim, within a reasonable period of time appropriate to the medical circumstances involved not to exceed thirty (30) days following receipt of the appeal; ii) When the appeal involves an Urgent Care Claim, as soon as possible taking into account the medical exigencies involved but not later than seventy-two (72) hours following receipt of the appeal; or iii) When the appeal involves a Post-service Claim, or a decision by the Plan to rescind coverage or deny an enrollment request because the individual is not eligible for coverage, within a reasonable period of time not to exceed thirty (30) days following receipt of the appeal. g. If the Plan fails to provide notice of its decision within the above-stated time frames or otherwise fails to strictly adhere to these appeal procedures, the Member may be permitted to request an external review and/or pursue any applicable right to arbitration. h. In the event that the Plan renders an adverse decision on the internal appeal, the notification shall include, among other items, the specific reason or reasons for the adverse decision and a statement regarding the right of the Member to request an external review and/or pursue any applicable right to arbitration.