Medical Appeal Procedures A Sample Clauses

Medical Appeal Procedures A. Medical Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because we determined one of the following:  The services were not medically necessary; or  The services are experimental or investigational. If we deny payment for a service for medical reasons, you will receive the denial in writing. The written denial you receive will:  explain the reason for the denial,  explain the clinical criteria that was used to make the determination,  provide specific instruction for obtaining the clinical criteria for the denial. To file a medical appeal verbally, you may call our Customer Service Department. You may also file a medical appeal in writing. To do so, you must provide the following information:  name, address, and member ID number;  summary of the medical appeal, any previous contact with Blue Cross & Blue Shield of Rhode Island, and a brief description of the relief or solution you are seeking;  any more information such as referral forms, claims, or any other documentation that you would like us to review;  the date of service; and  your signature. If a medical appeal is being filed on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Written medical appeals should be sent to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 Your doctor may also file a medical appeal on your behalf. Your doctor can contact the Physician and Provider Service Center to start the medical appeal. Within ten (10) business days of receipt of a written or verbal medical appeal, the Grievance and Appeals Unit will mail or call you to phone acknowledge of our receipt of the medical appeal. You are entitled to the following levels of review when seeking a medical appeal.