Common use of Medical Appeals Clause in Contracts

Medical Appeals. appeal is a request for us to reconsider a full or partial denial of payment for  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. 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. appeal is a request for us to reconsider a full or partial denial of payment for  • 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. 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.