Common use of Filing an Appeal Clause in Contracts

Filing an Appeal. The Carrier maintains procedures for the resolution of Member Appeals. Member Appeals may be filed within one hundred eighty (180) days of the receipt of a decision from the Carrier stating an adverse benefit determination. An Appeal occurs when the Member or, after obtaining the Member’s authorization, either the Provider or another authorized representative requests a change of a previous decision made by the Carrier by following the procedures described here. (In order to authorize someone else to be the Member’s representative for the Appeal, the Member must complete a valid authorization form. The Member must contact the Carrier as directed below to obtain a “Member/Enrollee Authorization to Appeal by Provider or Other Representative” form or for questions regarding the requirements for an authorized representative.) The Member or other authorized person on behalf of the Member, may request an Appeal by calling or writing to the Carrier, as defined in the letter notifying the Member of the decision or as follows: Member Appeals Department Toll Free Phone: ▇-▇▇▇-▇▇▇-▇▇▇▇ P.O. Box 41820 Toll Free Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ or Philadelphia, PA, ▇▇▇▇▇-▇▇▇▇. Phila. Fax: ▇▇▇-▇▇▇-▇▇▇▇ Types of Member Appeals and Applicable Timeframes. Following are the two types of Member Appeals and the issues they address: • Medical Necessity Appeal – An Appeal by or on behalf of a Member that focuses on issues of Medical Appropriateness/Medical Necessity and requests the Carrier to change its decision to deny or limit the provision of a Covered Service. Medical Necessity Appeals include Appeals of adverse benefit determinations based on the exclusions for Experimental/Investigative or cosmetic services. • Administrative Appeal – An Appeal by or on behalf of a Member that focuses on unresolved Member disputes or objections regarding a Carrier decision that concerns coverage terms such as contract exclusions and non- covered benefits, exhausted benefits, and claims payment issues. Although an Administrative Appeal may present issues related to Medical Appropriateness/Medical Necessity, these are not the primary issues that affect the outcome of the Appeal.

Filing an Appeal. The Carrier maintains procedures for the resolution of Member Appeals. Member Appeals may be filed within one hundred eighty (180) days of the receipt of a decision from the Carrier stating an adverse benefit determination. An Appeal occurs when the Member or, after obtaining the Member’s authorization, either the Provider or another authorized representative requests a change of a previous decision made by the Carrier by following the procedures described here. (In order to authorize someone else to be the Member’s representative for the Appeal, the Member must complete a valid authorization form. The Member must contact the Carrier as directed below to obtain a “Member/Enrollee Authorization to Appeal by Provider or Other Representative” form or for questions regarding the requirements for an authorized representative.) The Member or other authorized person on behalf of the Member, may request an Appeal by calling or writing to the Carrier, as defined in the letter notifying the Member of the decision or as follows: Member Appeals Department Toll Free Phone: ▇-▇▇▇-▇▇▇-▇▇▇▇ P.O. Box 41820 Toll Free Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ or Philadelphia, PA, ▇▇▇▇▇-▇▇▇▇. Phila. Fax: ▇▇▇-▇▇▇-▇▇▇▇ Types of Member Appeals and Applicable Timeframes. Following are the two types of Member Appeals and the issues they address: • Medical Necessity Appeal – An Appeal by or on behalf of a Member that focuses on issues of Medical Appropriateness/Medical Necessity and requests the Carrier to change its decision to deny or limit the provision of a Covered Service. Medical Necessity Appeals include Appeals of adverse benefit determinations based on the exclusions for Experimental/Investigative or cosmetic services. • Administrative Appeal – An Appeal by or on behalf of a Member that focuses on unresolved Member disputes or objections regarding a Carrier decision that concerns coverage terms such as contract exclusions and non- non-covered benefits, exhausted benefits, and claims payment issues. Although an Administrative Appeal may present issues related to Medical Appropriateness/Medical Necessity, these are not the primary issues that affect the outcome of the Appeal.. The timeframes described below for completing a review of each Appeal depend on additional classifications: