Common use of Initiating an Appeal Clause in Contracts

Initiating an Appeal. These internal appeal procedures are designed by the Health Plan to assure that concerns are fairly and properly heard and resolved. These procedures apply to a request for reconsideration of a Coverage Decision rendered by the Health Plan regarding any aspect of the Health Plan’s health care Service. The Member or the Member’s Authorized Representative must file an internal appeal within one-hundred eighty (180) calendar days from the date of receipt of the Coverage Decision. The Appeal should be sent to us at the following address: In addition, the Member or the Member’s Authorized Representative may request an internal appeal by contacting Member Services. The Member or the Member’s Authorized Representative, as applicable, may review the Health Plan’s appeal file and provide evidence and testimony to support the appeal request. Member Service Representatives are available by telephone each day during business hours to describe how internal appeals are processed and resolved and to assist with filing an internal appeal. The Member Service Representative can be contacted Monday through Friday from 7:30 a.m. to 9 p.m. ET within the local service area at ▇▇▇-▇▇▇-▇▇▇▇ or TTY 711. Along with your appeal, you may also send additional information including comments, documents or additional medical records which you believe supports your claim. If we had asked for additional information before and you did not provide it, you may still submit the additional information with your appeal. In addition, you may also provide testimony in writing or by telephone. Written testimony may be sent along with your appeal to the address listed above. To arrange to give testimony by telephone, you may contact the Member Services Appeal Unit. The Health Plan will add all additional information to your claim file and will revise all new information without regard to whether this information was submitted and/or considered in its initial decision. In addition, prior to rendering its final decision, the Health Plan will provide the Member or Member’s Authorized Representative,, without charge, any new or additional evidence considered, relied upon, or generated by (or at the direction of ) the Health Plan in connection with the Member or Member’s Authorized Representative appeal. If during the Health Plan’s review of the Member or Member’s Authorized Representative appeal, it determines that an adverse coverage decision can be made based on a new or additional rationale, the Health Plan will provide the Member or Member’s Authorized Representative with this new information prior to issuing its final coverage decision and explain how you can respond to the information if you choose to do so. The additional information will be provided to the Member or Member’s Authorized Representative as soon as possible and sufficiently before the deadline to give the Member or Member’s Authorized Representative a reasonable opportunity to respond to the new information. Health Plan will respond in writing to an Appeal within thirty (30) calendar days for a pre-service claim, or sixty (60) calendar days for a post-service claim after our receipt of the Appeal. If our review results in a denial, we will notify your and your Authorized Representative in writing within three (3) calendar days after the Appeal Decision has been verbally communicated. This notification will include:

Initiating an Appeal. These internal appeal Appeal procedures are designed by the Health Plan to assure that concerns are fairly and properly heard and resolved. These procedures apply to a request for reconsideration of a Coverage Decision rendered by the Health Plan regarding Plan, in regard to any aspect of the Health Plan’s health care Health Care Service. The Member You or the Member’s your Authorized Representative must file an internal appeal Appeal within one-hundred eighty (180) calendar days from the date of receipt of the Coverage Decision. The Appeal should be sent to us at the following address: In addition▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇, the Member ▇▇ ▇▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ You or the Member’s your Authorized Representative may request also initiate an internal appeal Appeal by contacting Member Services. The Member or the Member’s Authorized Representative, as applicable, may review the Health Plan’s appeal file and provide evidence and testimony to support the appeal request. Member Service Representatives are available by telephone each day during business hours to describe how internal appeals are processed and resolved and to assist with filing an internal appeal. The Member Service Representative can be contacted Services Monday through Friday from between 7:30 a.m. to and 9 p.m. ET within the local service area at ▇-▇▇▇-▇▇▇-▇▇▇▇ or TTY 711711 (TTY). Member Services Representatives are also available to describe to you or your Authorized Representative how Appeals are processed and resolved. You or your Authorized Representative, as applicable, may review the Health Plan’s Appeal file and provide evidence and testimony to support the Appeal request. Along with your appealan Appeal, you or your Authorized Representative may also send additional information including comments, documents or additional medical records which you believe supports your that are believed to support the claim. If we had asked for the Health Plan requested additional information before and you or your Authorized Representative did not provide it, you may still submit the additional information may still be submitted with your appealthe Appeal. In additionAdditionally, you testimony may also provide testimony be given in writing or by telephone. Written testimony may be sent along with your appeal the Appeal to the address listed above. To arrange to give provide testimony by telephone, you may contact the Member Services Appeal UnitMonday through Friday between 7:30 a.m. and 9 p.m. at ▇-▇▇▇-▇▇▇-▇▇▇▇ or 711 (TTY). The Health Plan will add all additional information to your the claim file and will revise review all new information without regard to regardless of whether this information was submitted and/or considered in its while making the initial decision. In addition, prior Prior to rendering its final decision, the Health Plan will provide the Member you or Member’s your Authorized Representative,, without charge, Representative with any new or additional evidence considered, relied upon, upon or generated by (or at the direction of of) the Health Plan in connection with the Member or Member’s Authorized Representative appealAppeal, at no charge. If during the Health Plan’s review of the Member or Member’s Authorized Representative appealAppeal, it determines we determine that an adverse coverage decision Coverage Decision can be made based on a new or additional rationale, the Health Plan then we will provide the Member you or Member’s your Authorized Representative with this new information prior to issuing its our final coverage decision and will explain how you or your Authorized Representative can respond to the information information, if you choose to do sodesired. The additional information will be provided to the Member you or Member’s your Authorized Representative as soon as possible possible, and sufficiently before the deadline to give the Member or Member’s Authorized Representative provide a reasonable opportunity to respond to the new information. After the Health Plan will respond in writing to an Appeal within thirty (30) calendar days for a pre-service claim, or sixty (60) calendar days for a post-service claim after our receipt of receives the Appeal. If our review results in a denial, we will notify your and respond to you or your Authorized Representative in writing within three (3) calendar days after the Appeal Decision has been verbally communicated. This notification will includewithin: