Common use of Medical Appeals Clause in Contracts

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. 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. 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 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 within thirty (1530) calendar days, from the receipt of your appeal. At any time during the review process, for a prospective or concurrent review; 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  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 formularyAppeals Unit. 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 preauthorization review), you or your healthcare provider should call the our 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.