Referral of Member to community resources Sample Clauses

Referral of Member to community resources. Appealing a Utilization Management Decision If the Member, the Member’s representative or the Member’s provider disagrees with a Utilization Management decision, Evergreen will review the decision upon the Member’s request. A Utilization Management appeal will be reviewed and decided upon by the Evergreen Medical Director or Associate Medical Director not involved in the initial denial decision. If necessary, the Medical Director or Associate Medical Director will discuss the Member’s case with the Member’s physician and/or request the opinion of a Specialist board certified in the same specialty as the treatment under review. Any non− certification or penalty may be appealed pursuant to Evergreen’s appeals and grievance procedures.
Sample 1

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