Common use of INTERNAL GRIEVANCE PROCEDURE Clause in Contracts

INTERNAL GRIEVANCE PROCEDURE. 1. A grievance must be filed within 180 days from the date of receipt of the written notice of any Adverse Benefit Determination. 2. A Member or authorized representative should first contact CareFirst about a denial of benefits. CareFirst can provide information and assistance on how to file a grievance. All grievances filed should be in writing, except grievances involving Urgent/Emergent Care which may be submitted orally or in writing. SAMPLE 3. The Member or authorized representative may submit written comments, documents, records, and other information relating to a claim for benefits. 4. The grievance decision for Urgent/Emergent Care claim shall be made as soon as possible but no later than the earlier of 24 hours after CareFirst’s receipt of the necessary information to make the decision regarding request for coverage, or 72 hours after receipt of the request for coverage. 5. A Member shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Member's claim for benefits. A document, record, or other information shall be considered relevant to a Member's claim if it: a. Was relied upon in making the benefit determination; b. Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; or, c. Demonstrates compliance with the administrative processes and safeguards designed to ensure and verify that benefit claim determinations are made in accordance with governing plan documents and that, where appropriate, the plan provisions have been applied consistently with respect to similarly situated members. 6. A grievance and any applicable documentation should be sent to the correspondence address stated on the reverse of the Member identification card. 7. Timing of CareFirst responses. The time limits for responding to a grievance will begin at the time an appeal is filed in accordance with these procedures, without regard to whether all the information necessary to make a decision is initially included. CareFirst will make a grievance decision and written notification will be sent: a. Within 30 days after receipt of the grievance for a case involving a Pre- Service Claim; b. Within 60 days after receipt of the grievance for a case involving a Post- Service Claim; and In the case of an expedited appeal regarding a claim relating to a prescription for the alleviation of cancer pain, the appeal decision shall be made as soon as possible but no later than 24 hours after receipt of the appeal. 8. When more information is needed for a decision. CareFirst will send notice within 5 working days of the receipt of the appeal that it cannot proceed with its review unless the additional information is provided. CareFirst will assist in gathering the necessary information. The response deadlines described above may be extended one time by CareFirst for up to 15 days, provided that CareFirst both: a. determines that such an extension is necessary due to matters beyond the control of CareFirst; and, b. notifies the Member, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which XxxxXxxxx expects to render a decision. If such an extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the Member shall be afforded at least 45 days from receipt of the notice within which to provide the specified information. SAMPLE In the event that a period of time is extended due to a Member's failure to submit necessary information, the period for responding to a grievance shall be tolled from the date on which the notification of the extension is sent to the Member until the date on which the Member responds to the request for additional information. The Member must agree to this extension in writing. The Member will be asked to sign a consent form.

INTERNAL GRIEVANCE PROCEDURE. SAMPLE 1. A grievance must be filed within 180 days from the date of receipt of the written notice of any Adverse Benefit Determination. 2. A Member or authorized representative should first contact CareFirst BlueChoice about a denial of benefits. CareFirst BlueChoice can provide information and assistance on how to file a grievance. All grievances filed should be in writing, except grievances involving Urgent/Emergent Care which may be submitted orally or in writing. SAMPLE. 3. The Member or authorized representative may submit written comments, documents, records, and other information relating to a claim for benefits. 4. The grievance decision for Urgent/Emergent Care claim shall be made as soon as possible but no later than the earlier of 24 hours after CareFirstCareFirst BlueChoice’s receipt of the necessary information to make the decision regarding request for coverage, or 72 hours after receipt of the request for coverage. 5. A Member shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Member's claim for benefits. A document, record, or other information shall be considered relevant to a Member's claim if it: a. Was relied upon in making the benefit determination; b. Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; or, c. Demonstrates compliance with the administrative processes and safeguards designed to ensure and verify that benefit claim determinations are made in accordance with governing plan documents and that, where appropriate, the plan provisions have been applied consistently with respect to similarly situated members. 6. A grievance and any applicable documentation should be sent to the correspondence address stated on the reverse of the Member identification card. 7. Timing of CareFirst BlueChoice responses. The time limits for responding to a grievance will begin at the time an appeal is filed in accordance with these procedures, without regard to whether all the information necessary to make a decision is initially included. CareFirst BlueChoice will make a grievance decision and written notification will be sent:. a. Within 30 days after receipt of the grievance for a case involving a Pre- Service Claim; b. Within 60 days after receipt of the grievance for a case involving a Post- Service Claim; and In the case of an expedited appeal regarding a claim relating to a prescription for the alleviation of cancer pain, the appeal decision shall be made as soon as possible but no later than 24 hours after receipt of the appeal. 8. When more information is needed for a decision. CareFirst BlueChoice will send notice within 5 working days of the receipt of the appeal that it cannot proceed with its review unless the additional information is provided. CareFirst BlueChoice will assist in gathering the necessary information. The response deadlines described above may be extended one time by CareFirst BlueChoice for up to 15 days, provided that CareFirst BlueChoice both:: SAMPLE a. determines that such an extension is necessary due to matters beyond the control of CareFirstCareFirst BlueChoice; and, b. notifies the Member, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which XxxxXxxxx CareFirst BlueChoice expects to render a decision. If such an extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the Member shall be afforded at least 45 days from receipt of the notice within which to provide the specified information. SAMPLE In the event that a period of time is extended due to a Member's failure to submit necessary information, the period for responding to a grievance shall be tolled from the date on which the notification of the extension is sent to the Member until the date on which the Member responds to the request for additional information. The Member must agree to this extension in writing. The Member will be asked to sign a consent form.

INTERNAL GRIEVANCE PROCEDURE. 1. A grievance must be filed within 180 days from the date of receipt of the written notice of any Adverse Benefit Determination. 2. A Member or authorized representative should first contact CareFirst about a denial of benefits. CareFirst can provide information and assistance on how to file a grievance. All grievances filed should be in writing, except grievances involving Urgent/Emergent Care which may be submitted orally or in writing. SAMPLE 3. The Member or authorized representative may submit written comments, documents, records, and other information relating to a claim for benefits. 4. The grievance decision for Urgent/Emergent Care claim shall be made as soon as possible but no later than the earlier of 24 hours after CareFirst’s receipt of the necessary information to make the decision regarding request for coverage, or 72 hours after receipt of the request for coverage. 5. A Member shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Member's claim for benefits. A document, record, or other information shall be considered relevant to a Member's claim if it: a. Was relied upon in making the benefit determination; b. Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; or, c. Demonstrates compliance with the administrative processes and safeguards designed to ensure and verify that benefit claim determinations are made in accordance with governing plan documents and that, where appropriate, the plan provisions have been applied consistently with respect to similarly situated members. 6. A grievance and any applicable documentation should be sent to the correspondence address stated on the reverse of the Member identification card. 7. Timing of CareFirst responses. The time limits for responding to a grievance will begin at the time an appeal is filed in accordance with these procedures, without regard to whether all the information necessary to make a decision is initially included. CareFirst will make a grievance decision and written notification will be sent: a. Within 30 days after receipt of the grievance for a case involving a Pre- Service Claim; b. Within 60 days after receipt of the grievance for a case involving a Post- Service Claim; and In the case of an expedited appeal regarding a claim relating to a prescription for the alleviation of cancer pain, the appeal decision shall be made as soon as possible but no later than 24 hours after receipt of the appeal. 8. When more information is needed for a decision. CareFirst will send notice within 5 working days of the receipt of the appeal that it cannot proceed with its review unless the additional information is provided. CareFirst will assist in gathering the necessary information. The response deadlines described above may be extended one time by CareFirst for up to 15 days, provided that CareFirst both: a. determines that such an extension is necessary due to matters beyond the control of CareFirst; and, b. notifies the Member, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which XxxxXxxxx CareFirst expects to render a decision. If such an extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the Member shall be afforded at least 45 days from receipt of the notice within which to provide the specified information. SAMPLE In the event that a period of time is extended due to a Member's failure to submit necessary information, the period for responding to a grievance shall be tolled from the date on which the notification of the extension is sent to the Member until the date on which the Member responds to the request for additional information. The Member must agree to this extension in writing. The Member will be asked to sign a consent form.

INTERNAL GRIEVANCE PROCEDURE. 1. A grievance must be filed within 180 days from the date of receipt of the written notice of any Adverse Benefit Determination. 2. A Member or authorized representative should first contact CareFirst about a denial of benefits. CareFirst can provide information and assistance on how to file a grievance. All grievances filed should be in writing, except grievances involving Urgent/Emergent Care which may be submitted orally or in writing. SAMPLE. 3. The Member or authorized representative may submit written comments, documents, records, and other information relating to a claim for benefits. 4. The grievance decision for Urgent/Emergent Care claim shall be made as soon as possible but no later than the earlier of 24 hours after CareFirst’s receipt of the necessary information to make the decision regarding request for coverage, or 72 hours after receipt of the request for coverage. 5. A Member shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Member's claim for benefits. A document, record, or other information shall be considered relevant to a Member's claim if it: a. Was relied upon in making the benefit determination; b. Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; or, c. Demonstrates compliance with the administrative processes and safeguards designed to ensure and verify that benefit claim determinations are made in accordance with governing plan documents and that, where appropriate, the plan provisions have been applied consistently with respect to similarly situated members. 6. A grievance and any applicable documentation should be sent to the correspondence address stated on the reverse of the Member identification card. 7. Timing of CareFirst responses. The time limits for responding to a grievance will begin at the time an appeal is filed in accordance with these procedures, without regard to whether all the information necessary to make a decision is initially included. CareFirst will make a grievance decision and written notification will be sent: a. Within 30 days after receipt of the grievance for a case involving a Pre- Service Claim; b. Within 60 days after receipt of the grievance for a case involving a Post- Service Claim; and In the case of an expedited appeal regarding a claim relating to a prescription for the alleviation of cancer pain, the appeal decision shall be made as soon as possible but no later than 24 hours after receipt of the appeal. 8. When more information is needed for a decision. CareFirst will send notice within 5 working days of the receipt of the appeal that it cannot proceed with its review unless the additional information is provided. CareFirst will assist in gathering the necessary information. The response deadlines described above may be extended one time by CareFirst for up to 15 days, provided that CareFirst both: a. determines that such an extension is necessary due to matters beyond the control of CareFirst; and, b. notifies the Member, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which XxxxXxxxx expects to render a decision. If such an extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the Member shall be afforded at least 45 days from receipt of the notice within which to provide the specified information. SAMPLE In the event that a period of time is extended due to a Member's failure to submit necessary information, the period for responding to a grievance shall be tolled from the date on which the notification of the extension is sent to the Member until the date on which the Member responds to the request for additional information. The Member must agree to this extension in writing. The Member will be asked to sign a consent form.

INTERNAL GRIEVANCE PROCEDURE. 1. A grievance must be filed within 180 days from the date of receipt of the written notice of any Adverse Benefit Determination. 2. A Member or authorized representative should first contact CareFirst BlueChoice about a denial of benefits. CareFirst BlueChoice can provide information and assistance on how to file a grievance. All grievances filed should be in writing, except grievances involving Urgent/Emergent Care which may be submitted orally or in writing. SAMPLE. 3. The Member or authorized representative may submit written comments, documents, records, and other information relating to a claim for benefits. 4. The grievance decision for Urgent/Emergent Care claim shall be made as soon as possible but no later than the earlier of 24 hours after CareFirstCareFirst BlueChoice’s receipt of the necessary information to make the decision regarding request for coverage, or 72 hours after receipt of the request for coverage. 5. A Member shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Member's claim for benefits. A document, record, or other information shall be considered relevant to a Member's claim if it: a. Was relied upon in making the benefit determination; b. Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; or, c. Demonstrates compliance with the administrative processes and safeguards designed to ensure and verify that benefit claim determinations are made in accordance with governing plan documents and that, where appropriate, the plan provisions have been applied consistently with respect to similarly situated members. 6. A grievance and any applicable documentation should be sent to the correspondence address stated on the reverse of the Member identification card. 7. Timing of CareFirst BlueChoice responses. The time limits for responding to a grievance will begin at the time an appeal is filed in accordance with these procedures, without regard to whether all the information necessary to make a decision is initially included. CareFirst BlueChoice will make a grievance decision and written notification will be sent:. a. Within 30 days after receipt of the grievance for a case involving a Pre- Service Claim; b. Within 60 days after receipt of the grievance for a case involving a Post- Service Claim; and In the case of an expedited appeal regarding a claim relating to a prescription for the alleviation of cancer pain, the appeal decision shall be made as soon as possible but no later than 24 hours after receipt of the appeal. 8. When more information is needed for a decision. CareFirst BlueChoice will send notice within 5 working days of the receipt of the appeal that it cannot proceed with its review unless the additional information is provided. CareFirst BlueChoice will assist in gathering the necessary information. The response deadlines described above may be extended one time by CareFirst BlueChoice for up to 15 days, provided that CareFirst BlueChoice both: a. determines that such an extension is necessary due to matters beyond the control of CareFirstCareFirst BlueChoice; and, b. notifies the Member, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which XxxxXxxxx CareFirst BlueChoice expects to render a decision. If such an extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the Member shall be afforded at least 45 days from receipt of the notice within which to provide the specified information. SAMPLE In the event that a period of time is extended due to a Member's failure to submit necessary information, the period for responding to a grievance shall be tolled from the date on which the notification of the extension is sent to the Member until the date on which the Member responds to the request for additional information. The Member must agree to this extension in writing. The Member will be asked to sign a consent form.

INTERNAL GRIEVANCE PROCEDURE. 1. A grievance must be filed within 180 days from the date of receipt of the written notice of any Adverse Benefit Determination. 2. A Member or authorized representative should first contact CareFirst about a denial of benefits. CareFirst can provide information and assistance on how to file a grievance. All grievances filed should be in writing, except grievances involving Urgent/Emergent Care which may be submitted orally or in writing. SAMPLE. 3. The Member or authorized representative may submit written comments, documents, records, and other information relating to a claim for benefits. 4. The grievance decision for UrgentXxxxxx/Emergent Care claim shall be made as soon as possible but no later than the earlier of 24 twenty-four (24) hours after CareFirst’s receipt of the necessary information to make the decision regarding request for coverage, or 72 seventy-two (72) hours after receipt of the request for coverage. 5. A Member shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Member's claim for benefits. A document, record, or other information shall be considered relevant to a Member's claim if it: a. a) Was relied upon in making the benefit determination; b. b) Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; or, c. c) Demonstrates compliance with the administrative processes and safeguards designed to ensure and verify that benefit claim determinations are made in accordance with governing plan documents and that, where appropriate, the plan provisions have been applied consistently with respect to similarly situated members. 6. A grievance and any applicable documentation should be sent to the correspondence address stated on the reverse of the Member identification card. 7. Timing of CareFirst responses. The time limits for responding to a grievance will begin at the time an appeal is filed in accordance with these procedures, without regard to whether all the information necessary to make a decision is initially included. CareFirst will make a grievance decision and written notification will be sent: a. a) Within 30 thirty (30) days after receipt of the grievance for a case involving a Pre- Pre-Service Claim; b. b) Within 60 sixty (60) days after receipt of the grievance for a case involving a Post- Post-Service Claim; and In the case of an expedited appeal regarding a claim relating to a prescription for the alleviation of cancer pain, the appeal decision shall be made as soon as possible but no later than 24 twenty-four (24) hours after receipt of the appeal. 8. When more information is needed for a decision. CareFirst will send notice within 5 five (5) working days of the receipt of the appeal that it cannot proceed with its review unless the additional information is provided. CareFirst will assist in gathering the necessary information. The response deadlines described above may be extended one time by CareFirst for up to 15 fifteen (15) days, provided that CareFirst both: a. determines a) Determines that such an extension is necessary due to matters beyond the control of CareFirst; and, b. notifies b) Notifies the Member, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which XxxxXxxxx CareFirst expects to render a decision. If such an extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the Member shall be afforded at least 45 forty-five (45) days from receipt of the notice within which to provide the specified information. SAMPLE In the event that a period of time is extended due to a Member's failure to submit necessary information, the period for responding to a grievance shall be tolled from the date on which the notification of the extension is sent to the Member until the date on which the Member responds to the request for additional information. The Member must agree to this extension in writing. The Member will be asked to sign a consent form.

INTERNAL GRIEVANCE PROCEDURE. 1. A grievance must be filed within 180 days from the date of receipt of the written notice of any Adverse Benefit Determination. 2. A Member or authorized representative should first contact CareFirst BlueChoice about a denial of benefits. CareFirst BlueChoice can provide information and assistance on how to file a grievance. All grievances filed should be in writing, except grievances involving Urgent/Emergent Care which may be submitted orally or in writing. SAMPLE. 3. The Member or authorized representative may submit written comments, documents, records, and other information relating to a claim for benefits. 4. The grievance decision for Urgent/Emergent Care claim shall be made as soon as possible but no later than the earlier of 24 hours after CareFirstCareFirst BlueChoice’s receipt of the necessary information to make the decision regarding request for coverage, or 72 hours after receipt of the request for coverage. 5. A Member shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Member's claim for benefits. A document, record, or other information shall be considered relevant to a Member's claim if it: a. Was relied upon in making the benefit determination; b. Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; or, c. Demonstrates compliance with the administrative processes and safeguards designed to ensure and verify that benefit claim determinations are made in accordance with governing plan documents and that, where appropriate, the plan provisions have been applied consistently with respect to similarly situated members. 6. A grievance and any applicable documentation should be sent to the correspondence address stated on the reverse of the Member identification card. 7. Timing of CareFirst BlueChoice responses. The time limits for responding to a grievance will begin at the time an appeal is filed in accordance with these procedures, without regard to whether all the information necessary to make a decision is initially included. CareFirst BlueChoice will make a grievance decision and written notification will be sent:. a. Within 30 days after receipt of the grievance for a case involving a Pre- Service Claim; b. Within 60 days after receipt of the grievance for a case involving a Post- Service Claim; and In the case of an expedited appeal regarding a claim relating to a prescription for the alleviation of cancer pain, the appeal decision shall be made as soon as possible but no later than 24 hours after receipt of the appeal.. SAMPLE 8. When more information is needed for a decision. CareFirst BlueChoice will send notice within 5 working days of the receipt of the appeal that it cannot proceed with its review unless the additional information is provided. CareFirst BlueChoice will assist in gathering the necessary information. The response deadlines described above may be extended one time by CareFirst BlueChoice for up to 15 days, provided that CareFirst BlueChoice both: a. determines that such an extension is necessary due to matters beyond the control of CareFirstCareFirst BlueChoice; and, b. notifies the Member, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which XxxxXxxxx CareFirst BlueChoice expects to render a decision. If such an extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the Member shall be afforded at least 45 days from receipt of the notice within which to provide the specified information. SAMPLE In the event that a period of time is extended due to a Member's failure to submit necessary information, the period for responding to a grievance shall be tolled from the date on which the notification of the extension is sent to the Member until the date on which the Member responds to the request for additional information. The Member must agree to this extension in writing. The Member will be asked to sign a consent form.