Medical Appeals. A medical appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services because we determined: the service was not medically necessary or appropriate; or the service was experimental or investigational. You may request an expedited appeal when: an urgent preauthorization request for healthcare services has been denied; the circumstances are an emergency; or you are in an inpatient setting. How to File a Medical Appeal You or your physician may file a written or verbal medical appeal with our Grievance and Appeals Unit. The medical appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. If someone other than your provider is filing a medical appeal on your behalf, you must provide us with a signed notice, authorizing the individual to represent you in this matter. 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 acknowledge our receipt of the medical appeal. You will receive written notification of our determination within: fifteen (15) calendar days, from the receipt of your appeal, for a prospective or concurrent review; and fifteen (15) business days, from the receipt of your appeal, for a retrospective review. See Prescription Drugs and Diabetic Equipment or Supplies in Section 3 for information on how to request coverage for a prescription drug not listed on our formulary.
Medical Appeals. A medical appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services because we determined: • the service was not medically necessary or appropriate; or • the service was experimental or investigational. You may request an expedited appeal when: • an urgent preauthorization request for healthcare services has been denied; • the circumstances are an emergency; or • you are in an inpatient setting. How to File a Medical Appeal You or your physician may file a written or verbal medical appeal with our Grievance and Appeals Unit. The medical appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. If someone other than your provider is filing a medical appeal on your behalf, you must provide us with a signed notice, authorizing the individual to represent you in this matter. You will receive written notification of our determination within thirty (30) calendar days from the receipt of your appeal. At any time during the review process, you may supply additional information to us. You may also request copies of information relevant to your request (free of charge) by contacting our Grievance and Appeals Unit.
Medical Appeals. Medical Appeals involve Adverse Benefit Determinations for Medical Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational and any related prospective or retrospective review determination. We offer the Member two (2) standard levels of medical Appeals, including an internal review of the initial Adverse Benefit Determination, then an external review. Medical Appeals should be submitted in writing to: Blue Cross and Blue Shield of Louisiana Medical Appeals P. O. Box 98022 Baton Rouge, LA 70898-9022
Medical Appeals. A medical appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services because we determined: • the service was not medically necessary or appropriate; or • the service was experimental or investigational. You may request an expedited appeal when: • an urgent preauthorization request for healthcare services has been denied; • the circumstances are an emergency; or • you are in an inpatient setting. How to File a Medical Appeal You or your physician may file a written or verbal medical appeal with our Grievance and Appeals Unit. The medical appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. If someone other than your provider is filing a medical appeal on your behalf, you must provide us with a signed notice, authorizing the individual to represent you in this matter. 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 acknowledge our receipt of the medical appeal. You will receive written notification of our determination within thirty (30) calendar days from the receipt of your appeal. At any time during the review process, you may supply additional information to us. You may also request copies of information relevant to your request (free of charge) by contacting our Grievance and Appeals Unit.
Medical Appeals. If you disagree with a full or partial medical denial made by Medicare, you may dispute the decision through the Medicare appeals process. To start this process, follow the directions given in the letter you receive from Medicare about the denial. We do not process Medicare medical appeals. In the event we deny payment of an amount for which this plan is responsible for a medical reason, you may dispute the denial with us. A medical appeal under this plan is a request for us to reconsider a full or partial denial of payment for services because we determined: • the service was not medically necessary or appropriate; or • the service was experimental or investigational. You may request an expedited appeal when: • an urgent preauthorization request for healthcare services has been denied; • the circumstances are an emergency; or • you are in an inpatient setting. How to File a Medical Appeal
Medical Appeals. A medical appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services because we determined: the service was not medically necessary or appropriate; or the service was experimental or investigational. You may request an expedited appeal when: an urgent preauthorization request for healthcare services has been denied; the circumstances are an emergency; or you are in an inpatient setting. How to File a Medical Appeal You or your physician may file a written or verbal medical appeal with our Grievance and Appeals Unit. The medical appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. If someone other than your provider is filing a medical appeal on your behalf, you must provide us with a signed notice, authorizing the individual to represent you in this matter. 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 acknowledge our receipt of the medical appeal. You will receive written notification of our determination within: fifteen (15) calendar days, from the receipt of your appeal, for a prospective or concurrent review; and fifteen (15) business days, from the receipt of your appeal, for a retrospective review. See Prescription Drugs and Diabetic Equipment or Supplies in Section 3 for information on how to request coverage for a prescription drug not listed on our formulary. How to File an Expedited Appeal Your appeal may require immediate action if a delay in treatment could seriously jeopardize your health or your ability to regain maximum function, or would cause you severe pain. To request an expedited appeal of a denial related to services that have not yet been rendered (a prospective review) or for on-going services (a concurrent review), you or your healthcare provider should call the Grievance and Appeals Unit. See Section 9 for contact information. You will be notified of our decision no later than seventy-two (72) hours or two (2) business days after our receipt of the request, whichever is shorter. You may not request an expedited review of covered healthcare services already received.
Medical Appeals. Medical Appeals involve a denial or partial denial based on Medical Necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or Investigational.
Medical Appeals. When the Administrator has ruled that a Member is not eligible for Core LTD Benefits hereunder, and the Member has exhausted their appeal options with the Administrator, the Member can appeal the decision through the Board of Trustees, who will be responsible to schedule a medical appeal. A medical appeal shall be subject to the following provisions:
Medical Appeals. This medical appeal procedure is for the purpose of resolving claims based upon medical grounds filed by individual teachers for exemption from assignment or reassignment. The procedure includes a District medical decision by the Employee Health Panel based on medical criteria, and a hearing of an appeal from such decision by the Medical Appeal Panel if requested by the employee. For purposes of conducting hearings of appeals from District medical decisions, the District and UTLA shall jointly select and retain a professional hearing officer who shall be a member of the American Arbitration Association's Labor Panel and who shall be compensated by the District and UTLA jointly. The District and UTLA shall each designate a representative to assist in the medical exemption appeal process. The hearing officer and the respective appointed representatives will serve as a Medical Appeal Panel chaired by the hearing officer. The Medical Appeal Panel shall have responsibility for hearing the appeal of each employee who files a written request for appeal from the Employee Health Panel decision. Based upon this hearing the Medical Appeal Panel will have the authority to sustain or reverse the Employee Health Panel's decision concerning the employee. At the conclusion of the hearing the Medical Appeal Panel shall make known its decision as soon as possible and the hearing officer shall prepare a written report of findings and conclusions. The decision shall be final and not subject to further appeal or to the grievance procedures of Article V.
