Common use of WHEN YOU HAVE AN APPEAL Clause in Contracts

WHEN YOU HAVE AN APPEAL. After you find out about an adverse benefit decision, you can ask for an internal appeal. Your plan has one internal appeal level. Your internal appeal will be reviewed by people who were not involved in the initial adverse benefit determination. If the adverse benefit determination involved medical judgment, the review will be done by a provider. They will review all of the information about your appeal and will give you a written decision. If you are not satisfied with the decision, you may ask for an external review. This is described below. Who may file an internal appeal You may file an appeal for yourself. You can also appoint someone to do it for you. This can be your doctor or provider. To appoint a representative, you must sign an authorization form and send it to us. The address and fax number are listed on the back cover. This release gives us your approval for this person to appeal on your behalf and allows our release of information, if any, to them. If you appoint someone else to act for you, that person can do any of the tasks listed below in this booklet that you would need to do. Please call us for an Authorization For Release form. You can also get a copy of this form on our website at xxxxxxx.xxx. How to file an internal appeal You may file an appeal by calling Customer Service or by writing to us at the address listed on the back cover. We must receive your internal appeal request within 180 calendar days of the date you were notified of the adverse benefit determination. You may send your written appeal request to the address or fax number on the back cover. If you need help filing an appeal, or would like a copy of the appeals process, please call Customer Service at the number listed on the back cover. You can also get a description of the appeals process by visiting our website at xxxxxxx.xxx. We will confirm in writing that we have your request within 72 hours. What if my situation is clinically urgent? If your provider believes that your situation is urgent under law, we will expedite your appeal; for example: • Your doctor thinks a delay may put your life or health in serious jeopardy or would subject you to pain that you cannot tolerate • The appeal is related to inpatient or emergency services and you are still in the emergency room or in the ambulance We will not expedite your appeal if you have already received the services you are appealing, or if you do not meet the above requirements. Please call Customer Service if you want to expedite your appeal. The number is listed on the back cover. If your situation is clinically urgent, you may also ask for an expedited external review at the same time you request an expedited internal appeal. Can I provide more information for my appeal? You may give us more information to support your appeal either at the time you file an appeal or at a later date. Mail or fax the information to the address and fax number listed on the back cover. Please give us this information as soon as you can. Can I get copies of information relevant to my appeal? We will also send you any new or additional information we considered, relied upon or generated in connection to your appeal. We will send it as soon as possible and free of charge. You will have the chance to review it and respond to us before we make our decision. What happens next? We will review your appeal and give you a written decision within the time limits below: • For expedited appeals, as soon as possible, but no later than 72 hours after we got your request. We will call, fax or email and then follow up in writing. • For appeals for benefit decisions made before you received the services, within 14 days of the date we got your request. • For appeals of experimental and investigational denials, within 20 days. Only with your informed consent may the review period be extended. • For all other appeals, within 14 days of the date we got your request. If we need more time to review your request, we may extend the review to no more than 30 days, unless we ask for and receive your agreement for more time after the 30 days. We will send you a notice (see Notice) of our decision and the reasons for it. If we uphold our initial decision, we will tell you about your right to an external review at the end of the internal appeals process. You can also go to the next appeal step if we do not comply with the rules above when we handle your appeal. Appeals about ongoing care If you appeal a decision to change, reduce or end coverage of ongoing care because the service is no longer medically necessary or appropriate, we will suspend our denial of benefits during the appeal period. Our provision of benefits for services received during the internal appeal period does not, and should not be assumed to, reverse our denial. If our decision is upheld, you must repay us all amounts that we paid for such services. You will also be responsible for any difference between our allowed amount and the provider's billed charge if the provider is non-contracting.

WHEN YOU HAVE AN APPEAL. After you find out about an adverse benefit decision, you can ask for an internal appeal. Your plan has one internal appeal level. Your internal appeal will be reviewed by people who were not involved in the initial adverse benefit determination. If the adverse benefit determination involved medical judgment, the review will be done by a provider. They will review all of the information about your appeal and will give you a written decision. If you are not satisfied with the decision, you may ask for an external review. This is described below. Who may file an internal appeal You may file an appeal for yourself. You can also appoint someone to do it for you. This can be your doctor or provider. To appoint a representative, you must sign an authorization form and send it to us. The address and fax number are listed on the back cover. This release gives us your approval for this person to appeal on your behalf and allows our release of information, if any, to them. If you appoint someone else to act for you, that person can do any of the tasks listed below in this booklet that you would need to do. Please call us for an Authorization For Release form. You can also get a copy of this form on our website at xxxxxxx.xxx. How to file an internal appeal You may file an appeal by calling Customer Service or by writing to us at the address listed on the back cover. We must receive your internal appeal request within 180 calendar days of the date you were notified of the adverse benefit determination. You may send your written appeal request to the address or fax number on the back cover. If you need help filing an appeal, or would like a copy of the appeals process, please call Customer Service at the number listed on the back cover. You can also get a description of the appeals process by visiting our website at xxxxxxx.xxx. We will confirm in writing that we have your request within 72 hours. What if my situation is clinically urgent? If your provider believes that your situation is urgent under law, we will expedite your appeal; for example: •  Your doctor thinks a delay may put your life or health in serious jeopardy or would subject you to pain that you cannot tolerate •  The appeal is related to inpatient or emergency services and you are still in the emergency room or in the ambulance We will not expedite your appeal if you have already received the services you are appealing, or if you do not meet the above requirements. Please call Customer Service if you want to expedite your appeal. The number is listed on the back cover. If your situation is clinically urgent, you may also ask for an expedited external review at the same time you request an expedited internal appeal. Can I provide more information for my appeal? You may give us more information to support your appeal either at the time you file an appeal or at a later date. Mail or fax the information to the address and fax number listed on the back cover. Please give us this information as soon as you can. Can I get copies of information relevant to my appeal? We will also send you any new or additional information we considered, relied upon or generated in connection to your appeal. We will send it as soon as possible and free of charge. You will have the chance to review it and respond to us before we make our decision. What happens next? We will review your appeal and give you a written decision within the time limits below: •  For expedited appeals, as soon as possible, but no later than 72 hours after we got your request. We will call, fax or email and then follow up in writing. •  For appeals for benefit decisions made before you received the services, within 14 days of the date we got your request. •  For appeals of experimental and investigational denials, within 20 days. Only with your informed consent may the review period be extended. •  For all other appeals, within 14 days of the date we got your request. If we need more time to review your request, we may extend the review to no more than 30 days, unless we ask for and receive your agreement for more time after the 30 days. We will send you a notice (see Notice) of our decision and the reasons for it. If we uphold our initial decision, we will tell you about your right to an external review at the end of the internal appeals process. You can also go to the next appeal step if we do not comply with the rules above when we handle your appeal. Appeals about ongoing care If you appeal a decision to change, reduce or end coverage of ongoing care because the service is no longer medically necessary or appropriate, we will suspend our denial of benefits during the appeal period. Our provision of benefits for services received during the internal appeal period does not, and should not be assumed to, reverse our denial. If our decision is upheld, you must repay us all amounts that we paid for such services. You will also be responsible for any difference between our allowed amount and the provider's billed charge if the provider is non-contracting.

WHEN YOU HAVE AN APPEAL. After you find out about an adverse benefit decision, you can ask for an internal appeal. Your plan has one internal appeal level. Your internal appeal will be reviewed by people who were not involved in the initial adverse benefit determination. If the adverse benefit determination involved medical judgment, the review will be done by a provider. They will review all of the information about your appeal and will give you a written decision. If you are not satisfied with the decision, you may ask for an external review. This is described below. Who may file an internal appeal You may file an appeal for yourself. You can also appoint someone to do it for you. This can be your doctor or provider. To appoint a representative, you must sign an authorization form and send it to us. The address and fax number are listed on the back cover. This release gives us your approval for this person to appeal on your behalf and allows our release of information, if any, to them. If you appoint someone else to act for you, that person can do any of the tasks listed below in this booklet that you would need to do. Please call us for an Authorization For Release form. You can also get a copy of this form on our website at xxxxxxx.xxxxxxxxxxxxx.xxx. How to file an internal appeal You may file an appeal by calling Customer Service or by writing to us at the address listed on the back cover. We must receive your internal appeal request within 180 calendar days of the date you were notified of the adverse benefit determination. You may send your written appeal request to the address or fax number on the back cover. If you need help filing an appeal, or would like a copy of the appeals process, please call Customer Service at the number listed on the back cover. You can also get a description of the appeals process by visiting our website at xxxxxxx.xxxxxxxxxxxxx.xxx. We will confirm in writing that we have your request within 72 hours. What if my situation is clinically urgent? If your provider believes that your situation is urgent under law, we will expedite your appeal; for example: •  Your doctor thinks a delay may put your life or health in serious jeopardy or would subject you to pain that you cannot tolerate •  The appeal is related to inpatient or emergency services and you are still in the emergency room or in the ambulance We will not expedite your appeal if you have already received the services you are appealing, or if you do not meet the above requirements. Please call Customer Service if you want to expedite your appeal. The number is listed on the back cover. If your situation is clinically urgent, you may also ask for an expedited external review at the same time you request an expedited internal appeal. Can I provide more information for my appeal? You may give us more information to support your appeal either at the time you file an appeal or at a later date. Mail or fax the information to the address and fax number listed on the back cover. Please give us this information as soon as you can. Can I get copies of information relevant to my appeal? We will also send you any new or additional information we considered, relied upon or generated in connection to your appeal. We will send it as soon as possible and free of charge. You will have the chance to review it and respond to us before we make our decision. What happens next? We will review your appeal and give you a written decision within the time limits below: •  For expedited appeals, as soon as possible, but no later than 72 hours after we got your request. We will call, fax or email and then follow up in writing. •  For appeals for benefit decisions made before you received the services, within 14 days of the date we got your request. •  For appeals of experimental and investigational denials, within 20 days. Only with your informed consent may the review period be extended. •  For all other appeals, within 14 days of the date we got your request. If we need more time to review your request, we may extend the review to no more than 30 days, unless we ask for and receive your agreement for more time after the 30 days. We will send you a notice (see Notice) of our decision and the reasons for it. If we uphold our initial decision, we will tell you about your right to an external review at the end of the internal appeals process. You can also go to the next appeal step if we do not comply with the rules above when we handle your appeal. Appeals about ongoing care If you appeal a decision to change, reduce or end coverage of ongoing care because the service is no longer medically necessary or appropriate, we will suspend our denial of benefits during the appeal period. Our provision of benefits for services received during the internal appeal period does not, and should not be assumed to, reverse our denial. If our decision is upheld, you must repay us all amounts that we paid for such services. You will also be responsible for any difference between our allowed amount and the provider's billed charge if the provider is non-contracting.

WHEN YOU HAVE AN APPEAL. After you find out about an adverse benefit decision, you can ask for an internal appeal. Your plan has one internal appeal level. Your internal appeal will be reviewed by people who were not involved in the initial adverse benefit determination. If the adverse benefit determination involved medical judgment, the review will be done by a provider. They will review all of the information about your appeal and will give you a written decision. If you are not satisfied with the decision, you may ask for an external review. This is described below. Who may file an internal appeal You may file an appeal for yourself. You can also appoint someone to do it for you. This can be your doctor or provider. To appoint a representative, you must sign an authorization form and send it to us. The address and fax number are listed on the back cover. This release gives us your approval for this person to appeal on your behalf and allows our release of information, if any, to them. If you appoint someone else to act for you, that person can do any of the tasks listed below in this booklet that you would need to do. Please call us for an Authorization For Release form. You can also get a copy of this form on our website at xxxxxxx.xxxxxxxxxxxxx.xxx. How to file an internal appeal You may file an appeal by calling Customer Service or by writing to us at the address listed on the back cover. We must receive your internal appeal request within 180 calendar days of the date you were notified of the adverse benefit determination. You may send your written appeal request to the address or fax number on the back cover. If you need help filing an appeal, or would like a copy of the appeals process, please call Customer Service at the number listed on the back cover. You can also get a description of the appeals process by visiting our website at xxxxxxx.xxxxxxxxxxxxx.xxx. We will confirm in writing that we have your request within 72 hours. What if my situation is clinically urgent? If your provider believes that your situation is urgent under law, we will expedite your appeal; for example: • Your doctor thinks a delay may put your life or health in serious jeopardy or would subject you to pain that you cannot tolerate • The appeal is related to inpatient or emergency services and you are still in the emergency room or in the ambulance We will not expedite your appeal if you have already received the services you are appealing, or if you do not meet the above requirements. Please call Customer Service if you want to expedite your appeal. The number is listed on the back cover. If your situation is clinically urgent, you may also ask for an expedited external review at the same time you request an expedited internal appeal. Can I provide more information for my appeal? You may give us more information to support your appeal either at the time you file an appeal or at a later date. Mail or fax the information to the address and fax number listed on the back cover. Please give us this information as soon as you can. Can I get copies of information relevant to my appeal? We will also send you any new or additional information we considered, relied upon or generated in connection to your appeal. We will send it as soon as possible and free of charge. You will have the chance to review it and respond to us before we make our decision. What happens next? We will review your appeal and give you a written decision within the time limits below: • For expedited appeals, as soon as possible, but no later than 72 hours after we got your request. We will call, fax or email and then follow up in writing. • For appeals for benefit decisions made before you received the services, within 14 days of the date we got your request. • For appeals of experimental and investigational denials, within 20 days. Only with your informed consent may the review period be extended. • For all other appeals, within 14 days of the date we got your request. If we need more time to review your request, we may extend the review to no more than 30 days, unless we ask for and receive your agreement for more time after the 30 days. We will send you a notice (see Notice) of our decision and the reasons for it. If we uphold our initial decision, we will tell you about your right to an external review at the end of the internal appeals process. You can also go to the next appeal step if we do not comply with the rules above when we handle your appeal. Appeals about ongoing care If you appeal a decision to change, reduce or end coverage of ongoing care because the service is no longer medically necessary or appropriate, we will suspend our denial of benefits during the appeal period. Our provision of benefits for services received during the internal appeal period does not, and should not be assumed to, reverse our denial. If our decision is upheld, you must repay us all amounts that we paid for such services. You will also be responsible for any difference between our allowed amount and the provider's billed charge if the provider is non-contracting.