Standard Appeals Sample Clauses
Standard Appeals. A standard appeal is a verbal or written request to review an adverse determination. 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 standard appeal applies to non-urgent, pre-service or retrospective pre-claim requests. Local specialty providers and independent review organizations are review consultants who may be utilized in the appeal process. Standard 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 standard appeal will be made within thirty (30) days of receipt of the request. To initiate a standard appeal:
(a) Call the Customer Service number listed on the back of the Member’s ID card or submit in writing as instructed on the original adverse determination letter.
(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 • Member reference number if known • Date of service • Name of facility where services are being rendered, if applicable • Name of ordering/attending physician • Any new clinical/medical record information Group acknowledges that it will have only one (1) standard appeal opportunity and agrees to submit all relevant clinical information with the appeal. Re-review appeal requests will not be accepted.
Standard Appeals. Any decision made by ESP of HHSI to deny, reduce or terminate a service or to deny payment for a service will be provided to you orally and in writing and will include an explanation of our reasons for the denial along with an explanation of your appeal rights.
Standard Appeals. You may file a formal written Appeal of an Adverse Benefit Determination with Coventry Health Care of Utah Grievances and Appeals Department. Any individual You designate as an authorized representative, including Your health care Provider, may also write an Appeal on Your behalf. A written Appeal must be filed no later than one-hundred eighty (180) calendar days from the date You received notification of the Adverse Benefit Determination. Coventry Health Care of Utah’s review of the Appeal will be based only on the information You provide, such as medical records. The Grievances and Appeals Department will investigate the issue, and submit the Appeal with all relevant information to the appropriate Appeals committee for review and determination. You or Your authorized representative may review the claim file and present information to the committee in writing or by telephone. None of the committee members will have been involved in the initial decision. The Appeals committee will notify You in writing of the decision within the following timeframes: Post Service Claims (services have already been obtained) – sixty (60) days from receipt of Your Appeal Pre Service Claims (services that have not been obtained) – thirty (30) days from receipt of Your Appeal If the Appeals committee intends to uphold the initial denial after reviewing the Appeal, Coventry Health Care of Utah will provide You with any new or additional information or rationale considered in the Appeal process. The information will be given to You as soon as possible, to allow You to respond prior to the date the committee’s final decision is due. Any additional information You choose to provide in response will be presented to the Appeals committee for a final decision.
Standard Appeals. (i) Appeals shall be decided, and written notice sent to the beneficiary as expeditiously as the beneficiary’s health requires and not more than 30 days after receipt of the internal appeal. The 30-day period begins with the receipt of the internal appeal and includes any review at the level of the Designated Agency(DA)/Specialized Service Agency (SSA).If an appeal cannot be resolved within 30 days, the timeframe may be extended up to an additional 14 days by request of the beneficiary, or by DVHA, if DVHA demonstrates (including to the satisfaction of AHS, upon its request) that there is a need for additional information and how the extension is in the best interest of the beneficiary. If the timeline is extended, DVHA must resolve the appeal as expeditiously as the beneficiary’s health condition requires and not later than the date the extension expires.
(ii) If DVHA extends the time frame and it is not at the request of the beneficiary, DVHA must make reasonable efforts to give the beneficiary prompt oral notice of the delay and, within 2 calendar days, must give the beneficiary written notice of the reason for the decision to extend the timeframe and inform the beneficiary of the right to file a grievance if s/he disagrees with the decision to extend the timeline. DocuSign Envelope ID: F73EF454-508D-44AC-ABD8-2A528194331A
Standard Appeals. The Contractor’s Appeals process must include the following requirements:
Standard Appeals. Appeals shall be decided, and written notice sent to the beneficiary as expeditiously as the beneficiary’s health requires and not more than 30 days after receipt of the internal appeal. The 30-day period begins with the receipt of the internal appeal and includes any review at the level of the Designated Agency(DA)/Specialized Service Agency (SSA).
Standard Appeals. Any decision made by EB ESP to deny, reduce or terminate a service or to deny payment for a service will be provided to you orally and in writing and will include an explanation of our reasons for the denial along with an explanation of your appeal rights. Be sure to address the FAX to EB ESP Compliance Director.