Level Formal Appeal. The 1st Level Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Such 180 days will run concurrently with the 180 day time period applicable to an Informal Review as set forth herein. NOTE: 1st Level Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. The 1st Level Formal Appeal shall contain at least the following information: • the Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number; • the Insured’s SHL membership number and Group name; and • a brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The 1st Level Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department PO Box 14865 Las Vegas, NV 89114 Fax: 0-000-000-0000 Certificate of Coverage SHL will investigate the appeal. When the investigation is complete, the Insured will be informed in writing of the resolution within thirty (30) days of receipt of the request for the 1st Level Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen (15) days, provided that the extension is necessary due to matters beyond the control of SHL and SHL notifies the Insured prior to the expiration of the initial thirty (30) day period of the circumstances requiring the extension and the date by which SHL expects to render a decision. If the extension is necessary due to a failure of the Insured to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information and the Insured shall be afforded at least forty-five (45) days from receipt of the notice to provide the information. If SHL is unable to resolve the Insureds appeal as additional information is required, SHL will contact the Insured to obtain their permission to withdraw the appeal. The Insured will receive written notification that the appeal that been withdrawn and...
Level Formal Appeal. The employee and/or the Association shall submit a written statement of appeal to the respondent within ten (10) workdays from the conclusion of the dialog outlined in part B. above. The appeal statement shall contain: 1) a statement of the relevant facts; 2) the management action or inaction which allegedly violated the Agreement; 3) the provisions of the Agreement allegedly violated; and 4) a proposed remedy which would resolve the appeal. The affected employee(s) may accompany the Association representative in presenting the appeal statement. The respondent shall review the appeal, if necessary, arrange a meeting for further discussion, and provide a written response to the employee(s) and the Association within ten (10) working days from the submission of the written appeal, or from the conclusion of the above contextual discussion, whichever is later.
Level Formal Appeal. If the resolution of the 2nd Level Formal Appeal results in an Adverse Benefit Determination, the Member will be informed in writing of the following: The specific reason or reasons for upholding the Adverse Benefit Determination; Reference to the specific Plan provisions on which the benefit determination is based; and A statement describing any additional voluntary levels of appeal. A statement describing the Member’s External Appeals Rights, if applicable, or judicial review. Limited extensions may be required if additional information is required or a formal presentation is requested and the Member agrees to the extension of time.
Level Formal Appeal. A 2nd Level Formal Appeal is submitted either orally or in writing and reviewed by the Grievance Review Committee. The 2nd Level Formal Appeal is voluntary for Adverse Benefit Determinations. Appeals that meet expedite criteria are not eligible for 2nd Level Formal Appeal. These may be processed through the expedited external review process.
