Common use of Level I Appeals Clause in Contracts

Level I Appeals. After you are notified of an adverse benefit determination, you may request a Level I internal appeal. Your Level I internal appeal will be reviewed by individuals who were not involved in making the initial adverse benefit determination. They will review all of the information relevant to your appeal and will provide a written determination. We will provide you a written notice acknowledging our receipt of your appeal request, and will notify you in writing of our decision within 14 days of receipt of your appeal unless we notify you that an extension to 30 days is necessary to complete the appeal. If 30 days is needed to complete your appeal, we must obtain your written consent. If you are not satisfied with our decision, you may request a Level II internal appeal. Level II Appeals Your Level II internal appeal will be reviewed by a panel that includes a health care Provider, if the adverse decision involved Medical Necessity, Experimental or Investigational services, or ongoing care, and other individuals who were not involved in the Level I appeal. You may participate in the Level II panel meeting in person or by phone to present evidence and testimony. We will provide you a written notice acknowledging our receipt of your appeal request, and will notify you in writing of our decision within 14 days of receipt of your appeal unless we notify you that an extension to 30 days is necessary to complete the appeal. If 30 days is needed to complete your appeal, we must obtain your written consent. If delay of your appeal would jeopardize your life or health, we will expedite the process with either a written or an oral appeal and issue a decision within 72 hours of receipt of your appeal. Please contact us for additional information about this process. Once the Level II review is complete, we will provide you with a written decision. If you are not satisfied with the Level II internal appeal decision, you may be eligible to request an external review, as described below. Filing Appeals You or your authorized representative may file an appeal by calling Customer Service or by writing to us at the address listed below. We must receive your appeal request within the following timelines: • For a Level I appeal, within 180 calendar days of the date you were notified of the adverse benefit determination; and • For a Level II appeal, within 60 calendar days of the date you were notified of the Level I determination. If you are hospitalized or traveling, or for other reasonable cause beyond your control, we will extend this timeline up to 180 calendar days to allow you to obtain additional medical documentation, physician consultations or opinions. You may submit your written appeal request to: Level I Appeals: FIRST CHOICE HEALTH ADMINISTRATORS Attn: Appeals Coordinator 000 Xxxxxxxxxx Xxxxxx, #0000 Seattle, WA 98101 Fax: (000) 000-0000 Level II Appeals: COMMUNITY HEALTH PLAN OF WASHINGTON Attn: Appeals Department 0000 Xxxxx Xxx, Xxxxx 000 Seattle, WA 98101 If you need help filing an appeal or would like a copy of the appeals process, please contact Customer Service at 0- 000-000-0000, Monday through Friday from 8am to 5pm, or email xxxxxxxxxxxx@xxxx.xxx. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.

Level I Appeals. After you are notified of an adverse benefit determination, you may can request a Level I internal appeal. Your Level I internal appeal will be reviewed by individuals who were not involved in making the initial adverse benefit determination. They will review all of the information relevant to your appeal and will provide a written determination. We will provide you a written notice acknowledging our receipt of your appeal request, request and will notify you in writing of our decision within 14 days of receipt of your appeal unless we notify you that an extension to 30 days is necessary to complete the appeal. If 30 days is needed to complete your appeal, we must obtain your written consent. If you are not satisfied with our the decision, you may request a Level II internal appeal. Level II Appeals Your Level II internal appeal will be reviewed by a panel that includes a health care Providerprovider, if the adverse decision involved Medical Necessitymedical necessity, Experimental or Investigational services, or ongoing care, and other individuals who were not involved in the Level I appeal. You may participate in the Level II panel meeting in person or by phone to present evidence and testimony. We will provide you a written notice acknowledging our receipt of your appeal request, request and will notify you in writing of our decision within 14 days of receipt of your appeal unless we notify you that an extension to 30 days is necessary to complete the appeal. If 30 days is needed to complete your appeal, we must obtain your written consent. If delay of your appeal would jeopardize your life or health, we will expedite the process with either a written or an oral appeal and issue a decision within 72 hours of receipt of your appeal. Please contact us for additional information about this process. Once the Level II review is complete, we will provide you with a written decisiondetermination. If you are not satisfied with the Level II final internal appeal decision, you may be eligible to request an external review, as described below. Filing Appeals You or your authorized representative may file an appeal by calling Customer Service or by writing to us at the address listed below. We must receive your appeal request within the following timelines: • For a Level I appeal, within 180 calendar days of the date you were notified of the adverse benefit determination; and • For a Level II appeal, within 60 calendar days of the date you were notified of the Level I determination. If you are hospitalized or traveling, or for other reasonable cause beyond your control, we will extend this timeline up to 180 calendar days to allow you to obtain additional medical documentation, physician consultations or opinions. You may submit your written appeal request to: Level I Appeals: FIRST CHOICE HEALTH ADMINISTRATORS Attn: Appeals Coordinator 000 Xxxxxxxxxx Xxxxxx, #0000 Seattle, WA 98101 Fax: (000) 000-0000 Level II Appeals: COMMUNITY HEALTH PLAN OF WASHINGTON Attn: Appeals Department 0000 Xxxxx Xxx, Xxxxx 000 Seattle, WA 98101 If you need help filing an appeal or would like a copy of the appeals process, please contact Customer Service at 0- 000-000-0000, Monday through Friday from 8am to 5pm, or email xxxxxxxxxxxx@xxxx.xxx. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.