Post Claim Appeals Clause Samples

Post Claim Appeals. An appeal is a written request to review a non-approved service or procedure that The Plan determines does not meet the requirements for Medical Necessity or is Experimental/Investigational/Unproven. The review is conducted by a peer reviewer who was not involved in the original adverse determination nor is the subordinate of the peer making the original adverse determination. A claim appeal applies to a post-service adverse determination. Local specialty providers and independent review organizations are review consultants who may be utilized in the appeal process. Post claim appeals may be requested within one hundred eighty (180) days from the date of notice of the original adverse determination letter. A final determination following the post claim appeal will be made within sixty (60) days of receipt of request. To initiate a post claim appeal: (a) All post claim appeals must be submitted in writing using the applicable appeals form or electronic process located in the Provider section of The Plan's website at ▇▇▇.▇▇▇▇▇▇.▇▇▇. (b) Have all related clinical information available for the denied services outlined in a letter/statement indicating the issue and resolution being sought which includes:  Name of the requestor  Phone number of the requestor  Member name  Member ID number  Reference number if known  Date of Service  Name of facility where services were rendered, if applicable  Name of ordering/attending physician  Any new clinical/medical record information Group acknowledges that it will have only one (1) appeal opportunity and agrees to submit all relevant clinical information with the appeal. Re-review appeal requests will not be accepted.