Common use of Post-Service Claim Clause in Contracts

Post-Service Claim. An Adverse Benefit Determination has been rendered for a service that has already been provided. Pre-Service Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided. Urgent Care Services Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided, where the application of non-urgent care appeal timeframes could seriously jeopardize: • Your life or health or your unborn child’s; or • In the opinion of the treating physician, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. INTERNAL APPEAL You, or your Authorized Representative, or a treating Provider or facility may submit an appeal. If you need assistance in preparing the appeal, or in submitting an appeal verbally, you may contact Alliant for such assistance at (000) 000-0000. You may submit appeals to the following addresses, dependent upon the type of appeal: Claims Appeals: Alliant Health Plans PO BOX 1247 Dalton, GA 30722 Alliant Health Plans c/o Magellan Rx Management Medical Appeals Department 000 Xxxxx Xxxx Xxxxxx, Xxxxx 000 Xxxx Xxxx Xxxx, XX 00000 Magellan Rx Management Appeals Department PO BOX 1599 Maryland Heights, MO 63043 Medical Appeals (Level I & II): Pharmacy Appeals (Level I & II): If you are Hearing impaired, you may also contact Alliant via the National Relay Service at 711. You (or your Authorized Representatives) must file an appeal within 180 days from the date of the notice of Adverse Benefit Determination. SPANISH (Español): Para obtener asistencia en Español, llame al (000) 000-0000. Within five business days of receiving an appeal (or 24 hours for appeals involving an Urgent Care Services Claim), Alliant will contact you (or your Authorized Representative) in writing or by telephone to inform you of any failure to follow Alliant’s internal appeal procedures. The appeal will be reviewed by personnel who were not involved in the making of the Adverse Benefit Determination and will include input from health care professional in the same or similar specialty as typically manages the type of medical service under review. TIMEFRAME FOR ALLIANT TO RESPOND TO APPEAL REQUEST TYPES TIMEFRAME FOR DECISION EXPEDITED APPEALS WITHIN 72 HOURS OR 3 CALENDAR DAYS PRE-SERVICE APPEALS (LEVEL I & II) WITHIN 15 DAYS POST-SERVICE APPEALS (LEVEL I & II) WITHIN 30 DAYS EXHAUSTION OF PROCESS The foregoing procedures and process are mandatory and must be exhausted prior to establishing litigation or arbitration or any administrative proceeding regarding matters within the scope of this Complaint and Appeals section. EXTERNAL APPEAL You may have the right to have our medical or pharmacy decision to deny a request or claim based on a determination of medical necessity, experimental/investigation status of the recommended treatment, the condition being considered, or a health care coverage rescission reviewed externally after you have exhausted the internal appeals rights provided by Alliant. You must file a request for an external review within 123 days after you receive notice of the denial of the claim orappeal. How do I request external review? You can submit a request for external review online at xxx.xxxxxxxxxxxxxx.xxx, by calling (000) 000-0000 to ask for an external review request form, or by sending the request via email to xxxx@xxxxxxx.xxx . To request an external review by fax or mail: MAXIMUS Federal Services 0000 Xxxxxx Xxxxxx, Xxxxx 000 Pittsford, NY 14534 Fax: (000) 000-0000 If you have any questions or concerns during the external appeal process, you (or your Authorized Representative) can call the toll-free number (000) 000-0000 or visit xxx.xxxxxxxxxxxxxx.xxx. How do I request an expedited external review? In some cases, you may ask for an expedited (faster than usual) external review. An expedited review may be requested when:

Post-Service Claim. An Adverse Benefit Determination has been rendered for a service that has already been provided. Pre-Service Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided. Urgent Care Services Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided, where the application of non-urgent care appeal timeframes could seriously jeopardize: • Your life or health or your unborn child’s; or • In the opinion of the treating physician, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. INTERNAL APPEAL You, or your Authorized Representative, or a treating Provider or facility may submit an appeal. If you need assistance in preparing the appeal, or in submitting an appeal verbally, you may contact Alliant for such assistance at (000) 000-0000. You may submit appeals to the following addresses, dependent upon the type of appeal: Medical & Administrative Claims Appeals: Alliant Health Plans PO BOX 1247 Dalton, GA 30722 Alliant Health Plans c/o MedPharm Appeals: Magellan Rx Management Medical Appeals Department 000 Xxxxx Xxxx XxxxxxPO BOX 1459 Maryland Heights, Xxxxx 000 Xxxx Xxxx Xxxx, XX 00000 MO 63043 Pharmacy Appeals: Magellan Rx Management Appeals Department PO BOX 1599 Maryland Heights, MO 63043 Medical Appeals (Level I & II): Pharmacy Appeals (Level I & II): If you are Hearing impaired, you may also contact Alliant via the National Relay Service at 711. You (or your Authorized Representatives) must file an initial appeal (Level I) within 180 days from the date of the notice of Adverse Benefit Determination. If your initial appeal is denied, you may file a second appeal (Level II) within 60 days from the date your initial (Level I) appeal was denied. SPANISH (Español): Para obtener asistencia en Español, llame al (000) 000-0000. Within five business days of receiving an appeal (or 24 hours for appeals involving an Urgent Care Services Claim), Alliant will contact you (or your Authorized Representative) in writing or by telephone to inform you of any failure to follow Alliant’s internal appeal procedures. The appeal will be reviewed by personnel who were not involved in the making of the Adverse Benefit Determination and will include input from health care professional in the same or similar specialty as typically manages the type of medical service under review. TIMEFRAME FOR ALLIANT TO RESPOND TO APPEAL REQUEST TYPES TIMEFRAME FOR DECISION EXPEDITED APPEALS WITHIN 72 HOURS OR 3 CALENDAR DAYS PRE-SERVICE APPEALS (LEVEL I & II) WITHIN 15 DAYS POST-SERVICE APPEALS (LEVEL I & II) WITHIN 30 DAYS EXHAUSTION OF PROCESS The foregoing procedures and process are mandatory and must be exhausted prior to establishing litigation or arbitration or any administrative proceeding regarding matters within the scope of this Complaint and Appeals section. EXTERNAL APPEAL You may have the right to have our medical or pharmacy decision to deny a request or claim based on a determination of medical necessity, experimental/investigation status of the recommended treatment, the condition being considered, or a health care coverage rescission reviewed externally after you have exhausted the internal appeals rights provided by Alliant. You must file a request for an external review within 123 days after you receive notice of the denial of the claim orappealclaimor appeal. How do I request external review? You can submit a request for external review online at xxx.xxxxxxxxxxxxxx.xxx, by calling (000) 000-0000 to ask for an external review request form, or by sending the request via email to xxxx@xxxxxxx.xxx . To request an external review by fax or mail: MAXIMUS Federal Services 0000 Xxxxxx Xxxxxx, Xxxxx 000 Xxxxx000 Pittsford, NY 14534 Fax: (000) 000000)000-0000 If you have any questions or concerns during the external appeal process, you (or your Authorized Representative) can call the toll-free number (000) 000-0000 or visit xxx.xxxxxxxxxxxxxx.xxx. How do I request an expedited external review? In some cases, you may ask for an expedited (faster than usual) external review. An expedited review may be requested when:

Post-Service Claim. An Adverse Benefit Determination has been rendered for a service that has already been provided. Pre-Service Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided. Urgent Care Services Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided, where the application of non-urgent care appeal timeframes could seriously jeopardize: • Your life or health or your Your unborn child’s; or • In the opinion of the treating physician, would subject you You to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. INTERNAL APPEAL You, or your Your Authorized Representative, or a treating Provider or facility may submit an appeal. If you You need assistance in preparing the appeal, or in submitting an appeal verbally, you You may contact Alliant for such assistance at (000) 000-0000. You may submit appeals to the following addresses, dependent upon the type of appeal: Medical & Administrative Claims Appeals: Alliant Health Plans PO BOX 1247 Dalton, GA 30722 Alliant Health Plans c/o Magellan Rx Management Medical Appeals Department 000 Xxxxx Xxxx XX XXX 0000 Xxxxxx, Xxxxx 000 Xxxx Xxxx Xxxx, XX 00000 MedPharm Appeals: Magellan Rx Management Appeals Department PO BOX 1599 Maryland HeightsXX XXX 0000 Xxxxxxxx Xxxxxxx, MO 63043 Medical XX 00000 Pharmacy Appeals: Magellan Rx Management Appeals (Level I & II): Pharmacy Appeals (Level I & II): Department XX XXX 0000 Xxxxxxxx Xxxxxxx, XX 00000 If you You are Hearing impaired, you You may also contact Alliant via the National Relay Service at 711. You (or your Your Authorized Representatives) must file an initial appeal (Level I) within 180 days from the date of the notice of Adverse Benefit Determination. If Your initial appeal is denied, You may file a second appeal (Level II) within 60 days from the date Your initial (Level I) appeal was denied. SPANISH (Español): Para obtener asistencia en Español, llame al (000) 000-0000. Within five business days of receiving an appeal (or 24 hours for appeals involving an Urgent Care Services Claim), Alliant will contact you You (or your Your Authorized Representative) in writing or by telephone to inform you You of any failure to follow Alliant’s internal appeal procedures. The appeal will be reviewed by personnel who were not involved in the making of the Adverse Benefit Determination and will include input from health care professional in the same or similar specialty as typically manages the type of medical service under review. TIMEFRAME FOR ALLIANT TO RESPOND TO APPEAL REQUEST TYPES TIMEFRAME FOR DECISION EXPEDITED APPEALS WITHIN 72 HOURS OR or 3 CALENDAR DAYS PRE-SERVICE APPEALS (LEVEL I & II) WITHIN 15 CALENDAR DAYS POST-SERVICE APPEALS (LEVEL I & II) WITHIN 30 CALENDAR DAYS EXHAUSTION OF PROCESS The foregoing procedures and process are mandatory and must be exhausted prior to establishing litigation or arbitration or any administrative proceeding regarding matters within the scope of this Complaint and Appeals section. EXTERNAL APPEAL You may have the right to have our Our medical or pharmacy decision to deny a request or claim based on a determination of medical necessity, experimental/investigation status of the recommended treatment, the condition being considered, or a health care coverage rescission reviewed externally after you You have exhausted the internal appeals rights provided by Alliant. You must file a request for an external review within 123 days after you You receive notice of the denial of the claim orappealor appeal. How do I request external review? You can submit a request for external review online at xxx.xxxxxxxxxxxxxx.xxx, by calling (000) 000-0000 to ask for an external review request form, or by sending the request via email to xxxx@xxxxxxx.xxx . To request an external review by fax or mail: MAXIMUS Federal Services 0000 Xxxxxx Xxxxxx, Xxxxx 000 PittsfordXxxxx000 Xxxxxxxxx, NY 14534 XX 00000 Fax: (000) 000000)000-0000 If you You have any questions or concerns during the external appeal process, you You (or your Your Authorized Representative) can call the toll-free number (000) 000-0000 or visit xxx.xxxxxxxxxxxxxx.xxx. How do I request an expedited external review? In some cases, you You may ask for an expedited (faster than usual) external review. An expedited review may be requested when:

Post-Service Claim. An Adverse Benefit Determination has been rendered for a service that has already been provided. Pre-Service Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided. Urgent Care Services Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided, where the application of non-urgent care appeal timeframes could seriously jeopardize: • Your life or health or your Your unborn child’s; or • In the opinion of the treating physician, would subject you You to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. INTERNAL APPEAL You, or your Your Authorized Representative, or a treating Provider or facility may submit an appeal. If you You need assistance in preparing the appeal, or in submitting an appeal verbally, you You may contact Alliant for such assistance at (000) 000-0000. You may submit appeals to the following addresses, dependent upon the type of appeal: Medical & Administrative Claims Appeals: Alliant Health Plans PO BOX 1247 Dalton, GA 30722 Alliant Health Plans c/o MedPharm Appeals: Magellan Rx Management Medical Appeals Department 000 Xxxxx Xxxx XxxxxxPO BOX 1459 Maryland Heights, Xxxxx 000 Xxxx Xxxx Xxxx, XX 00000 MO 63043 Pharmacy Appeals: Magellan Rx Management Appeals Department PO BOX 1599 Maryland Heights, MO 63043 Medical Appeals (Level I & II): Pharmacy Appeals (Level I & II): If you You are Hearing impaired, you You may also contact Alliant via the National Relay Service at 711. You (or your Your Authorized Representatives) must file an initial appeal (Level I) within 180 days from the date of the notice of Adverse Benefit Determination. If Your initial appeal is denied, You may file a second appeal (Level II) within 60 days from the date Your initial (Level I) appeal was denied. SPANISH (Español): Para obtener asistencia en Español, llame al (000) 000-0000. Within five business days of receiving an appeal (or 24 hours for appeals involving an Urgent Care Services Claim), Alliant will contact you You (or your Your Authorized Representative) in writing or by telephone to inform you You of any failure to follow Alliant’s internal appeal procedures. The appeal will be reviewed by personnel who were not involved in the making of the Adverse Benefit Determination and will include input from health care professional healthcare professionals in the same or similar specialty as typically manages the type of medical service under review. TIMEFRAME FOR ALLIANT TO RESPOND TO APPEAL REQUEST TYPES TIMEFRAME FOR DECISION EXPEDITED APPEALS WITHIN 72 HOURS OR 3 CALENDAR DAYS PRE-SERVICE APPEALS (LEVEL I & II) WITHIN 15 DAYS POST-SERVICE APPEALS (LEVEL I & II) WITHIN 30 DAYS EXHAUSTION OF PROCESS The foregoing procedures and process are mandatory and must be exhausted prior to establishing litigation or arbitration or any administrative proceeding regarding matters within the scope of this Complaint and Appeals section. EXTERNAL APPEAL You may have the right to have our Our medical or pharmacy decision to deny a request or claim based on a determination of medical necessity, experimental/investigation status of the recommended treatment, the condition being considered, or a health care coverage rescission reviewed externally after you You have exhausted the internal appeals rights provided by Alliant. You must file a request for an external review within 123 days after you You receive notice of the denial of the claim orappealor appeal. How do I request external review? You can submit a request for external review online at xxx.xxxxxxxxxxxxxx.xxx, by calling (000) 000-0000 to ask for an external review request form, or by sending the request via email to xxxx@xxxxxxx.xxx xxxx@xxxxxxx.xxx. To request an external review by fax or mail: MAXIMUS Federal Services 0000 Xxxxxx Xxxxxx, Xxxxx 000 PittsfordXxxxx000 Xxxxxxxxx, NY 14534 XX 00000 Fax: (000) 000000)000-0000 If you You have any questions or concerns during the external appeal process, you You (or your Your Authorized Representative) can call the toll-free number (000) 000-0000 or visit xxx.xxxxxxxxxxxxxx.xxx. How do I request an expedited external review? In some cases, you You may ask for an expedited (faster than usual) external review. An expedited review may be requested when:

Post-Service Claim. An Adverse Benefit Determination has been rendered for a service that has already been provided. Pre-Service Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided. Urgent Care Services Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided, where the application theapplication of non-urgent care appeal timeframes could seriously jeopardize: • Your life or health or your Your unborn child’s; or • In the opinion of the treating physician, would subject you You to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. INTERNAL APPEAL You, or your Your Authorized Representative, or a treating Provider or facility may submit an appeal. If you You need assistance in preparing the appeal, or in submitting an appeal verbally, you You may contact Alliant for such assistance at (000) 000-0000. You may submit appeals to the following addresses, dependent upon the type of appeal: Medical & Administrative Claims Appeals: Alliant Health Plans PO BOX 1247 Dalton, GA 30722 Alliant Health Plans c/o Magellan Rx Management Medical Appeals Department 000 Xxxxx Xxxx XX XXX 0000 Xxxxxx, Xxxxx 000 Xxxx Xxxx Xxxx, XX 00000 MedPharm Appeals: Magellan Rx Management Appeals Department PO BOX 1599 Maryland HeightsXX XXX 0000 Xxxxxxxx Xxxxxxx, MO 63043 Medical XX 00000 Pharmacy Appeals: Magellan Rx Management Appeals (Level I & II): Pharmacy Appeals (Level I & II): Department XX XXX 0000 Xxxxxxxx Xxxxxxx, XX 00000 If you You are Hearing impaired, you You may also contact Alliant via the National Relay Service at 711. You (or your Your Authorized Representatives) must file an initial appeal (Level I) within 180 days from the date of the notice of Adverse Benefit Determination. If Your initial appeal is denied, You may file a second appeal (Level II) within 60 days from thedate Your initial (Level I) appeal was denied. SPANISH (Español): Para obtener asistencia en Español, llame al (000) 000-0000. Within five business days of receiving an appeal (or 24 hours for appeals involving an Urgent Care Services Claim), Alliant will contact you You (or your Your Authorized Representative) in writing or by telephone to inform you You of any failure to follow Alliant’s internal appeal procedures. The appeal will be reviewed by personnel who were not involved in the making of the Adverse Benefit Determination and will include input from health care professional in the same or similar specialty as typically manages the type of medical service under review. TIMEFRAME FOR ALLIANT TO RESPOND TO APPEAL REQUEST TYPES TIMEFRAME FOR DECISION EXPEDITED APPEALS WITHIN 72 HOURS OR or 3 CALENDAR DAYS PRE-SERVICE APPEALS (LEVEL I & II) WITHIN 15 CALENDAR DAYS POST-SERVICE APPEALS (LEVEL I & II) WITHIN 30 CALENDAR DAYS EXHAUSTION OF PROCESS The foregoing procedures and process are mandatory and must be exhausted prior to establishing litigation or arbitration or any administrative anyadministrative proceeding regarding matters within the scope of this Complaint and Appeals section. EXTERNAL APPEAL You may have the right to have our Our medical or pharmacy decision to deny a request or claim based on a determination of medical necessity, experimental/investigation status of the recommended treatment, the condition being considered, or a health care coverage rescission reviewed externally after you You have exhausted the internal appeals rights provided by Alliant. You must file a request for an external review within 123 days after you You receive notice of the denial of the claim orappealor appeal. How do I request external review? You can submit a request for external review online at xxx.xxxxxxxxxxxxxx.xxx, by calling (000) 000-0000 to ask for an external review request form, or by sending the request via email to xxxx@xxxxxxx.xxx . To request an external review by fax or faxor mail: MAXIMUS Federal Services 0000 Xxxxxx Xxxxxx, Xxxxx 000 PittsfordXxxxx000 Xxxxxxxxx, NY 14534 XX 00000 Fax: (000) 000000)000-0000 If you You have any questions or concerns during the external appeal process, you You (or your Your Authorized Representative) can call the toll-free number (000) 000-0000 or visit xxx.xxxxxxxxxxxxxx.xxx. How do I request an expedited external review? In some cases, you You may ask for an expedited (faster than usual) external review. An expedited review may be requested when: