Your Right to Appeal. A Determination that A Service is Experimental or Investigational.
1. Standard health services are ineffective or medically inappropriate; or
2. There does not exist a more beneficial standard service or procedure covered by Us; or
3. There exists a clinical trial or rare disease treatment (as defined by law). In addition, Your attending Physician must have recommended one (1) of the following:
1. A service, procedure or treatment that two (2) documents from available medical and scientific evidence indicate is likely to be more beneficial to You than any standard Covered Service (only certain documents will be considered in support of this recommendation – Your attending Physician should contact the State for current information as to what documents will be considered or acceptable); or
2. A clinical trial for which You are eligible (only certain clinical trials can be considered); or
3. A rare disease treatment for which Your attending Physician certifies that there is no standard treatment that is likely to be more clinically beneficial to You than the requested service, the requested service is likely to benefit You in the treatment of Your rare disease, and such benefit outweighs the risk of the service. In addition, Your attending Physician must certify that Your condition is a rare disease that is currently or was previously subject to a research study by the National Institutes of Health Rare Disease Clinical Research Network or that it affects fewer than 200,000 U.S. residents per year. For purposes of this section, Your attending Physician must be a licensed, board-certified or board eligible Physician qualified to practice in the area appropriate to treat Your condition or disease. In addition, for a rare disease treatment, the attending Physician may not be Your treating Physician.
Your Right to Appeal an Out-of-Network Referral Denial to a Non-Participating Provider.
Your Right to Appeal a Determination that a Service is Out-of-Network.
Your Right to Appeal a Determination that a Service is Out-of-Network. If We have denied coverage of an out-of-network treatment because it is not materially different than the health service available in-network, You may appeal to an External Appeal Agent if You meet the two (2) requirements for an external appeal in paragraph “A” above, and You have requested Preauthorization for the out-of-network treatment. In addition, Your attending Physician must certify that the out-of-network service is materially different from the alternate recommended in-network health service, and based on two (2) documents from available medical and scientific evidence, is likely to be more clinically beneficial than the alternate in-network treatment and that the adverse risk of the requested health service would likely not be substantially increased over the alternate in-network health service. For purposes of this section, Your attending Physician must be a licensed, board certified or board eligible Physician qualified to practice in the specialty area appropriate to treat You for the health service.
Your Right to Appeal a Determination that a Service is Not Medically Necessary. If We have denied coverage on the basis that the service is not Medically Necessary, You may appeal to an External Appeal Agent if You meet the requirements for an external appeal in paragraph “A” above.
Your Right to Appeal. The plan administrator is required to let you know, in writing, if he or she denies your application for benefits payments. The plan administrator must give you specific reasons for the denial. You have the right to a full review of the denial by all the trustees of the plan. If you are still unhappy with the decision, you can file a lawsuit in federal district court.
Your Right to Appeal a determination that a service is not medically necessary
Your Right to Appeal. You have a right to appeal this Order to the Pollution Control Hearing Board (PCHB) within 30 days of the date of receipt of this Order. The appeal process is governed by Chapter 43.21B RCW and Chapter 371-08 WAC. “Date of receipt” is defined in RCW 43.21B.001(2). To appeal you must do both of the following within 30 days of the date of receipt of this Order: • File your appeal and a copy of this Order with the PCHB (see addresses below). Filing means actual receipt by the PCHB during regular business hours. • Serve a copy of your appeal and this Order on Ecology in paper form - by mail or in person. (See addresses below.) E-mail is not accepted. You must also comply with other applicable requirements in Chapter 43.21B RCW and Chapter 371-08 WAC.
Your Right to Appeal. A Determination that A Service is Experimental or Investigational.
1. Standard health services are ineffective or medically inappropriate; or
2. There does not exist a more beneficial standard service or procedure covered by Us; or
Your Right to Appeal. You have the right to appeal against the School's decision to refuse your Request. Such an appeal must be exercised in writing within 14 days after the day the School's decision is given, giving full details of why you wish to appeal. Your notice of appeal must be dated and sent to [the Bursary].
