Medical and pharmacy services. Members may request internal review of any adverse benefit determination relating to urgent care, pre-service claims, and post-ser- vice claims made by the plan’s medical and pharmacy vendors.
A. Appeals of adverse benefit deter- minations shall be submitted in writing to the vendor that issued the original determination giving rise to the appeal at the applicable address set forth in this rule.
B. The internal review process for adverse benefit determinations relating to medical services consists of two (2) levels of internal review provided by the medical ven- dor that issued the adverse benefit determina- tion.
(I) First level appeals must identify the decision being appealed and the reason the member believes the original claim deci- sion should be overturned. The member should include with his/her appeal any addi- tional information or documentation to sup- port the reason the original claim decision should be overturned.
(II) First level appeals will be reviewed by the vendor by someone who was not involved in the original decision and will consult with a qualified medical professional if a medical judgment is involved. First level medical appeals will be decided within twen- ty (20) business days from the date the vendor received the first level appeal request.
(a) If, because of reasons beyond the vendor’s control, more time is needed to review the appeal, the vendor may extend the time period up to an additional thirty (30) days. The vendor must notify the member prior to the expiration of the first twenty- (20-) day period, explain the reason for the delay, and request any additional information. If more information is requested, the member has at least forty-five (45) days to provide the information to the vendor. The vendor then must decide the claim no later than thirty (30) days after the additional information is sup- plied or after the period of time allowed to supply it ends, whichever is first. Written confirmation of the decision will be sent by the vendor within fifteen (15) business days.
(III) An expedited appeal of an adverse benefit determination may be requested when a decision is related to a pre- service claim for urgent care. Expedited appeals will be reviewed by the vendor by someone who was not involved in the original decision and will consult with a qualified medical professional if a medical judgment is involved. Expedited appeals will be respond- ed to within seventy-two (72) hours after receiving a request for an expedite...
