Utilization Review Appeals Sample Clauses
The Utilization Review Appeals clause establishes a process for challenging decisions made during utilization reviews, which assess the necessity and appropriateness of healthcare services. Typically, this clause outlines the steps a patient or provider must follow to appeal a denial or limitation of coverage, such as submitting additional documentation or requesting a secondary review by an independent party. Its core function is to provide a formal mechanism for disputing adverse determinations, ensuring that patients have a fair opportunity to contest decisions that may affect their access to care.
Utilization Review Appeals. If you disagree with a treatment plan, or you are requesting experimental or investigational health care services our utilization review unit may be able to help. If we decide to deny coverage for a medical service you and your doctor asked for because it is an experimental or investigational health care service, you can ask Fidelis for an appeal.
A. Standard Appeal A standard appeal must be filed by you or your representative, either in writing or by telephone, within 180 calendar days after you receive notice of the adverse determination. The Fidelis Utilization Review agent will send you a letter telling you that we know you have filed the appeal within fifteen (15) business days of your filing. Fidelis will make a decision on the appeal within sixty (30) days after receiving necessary information to conduct the appeal. The Fidelis Utilization Review agent will send you, your representative and, where appropriate, your doctor, a letter telling you about the appeal decision within two (2) business days of making this decision but no later than 30 calendar days after receipt of the appeal request . When Fidelis receives your request for an appeal, we will call your doctor or hospital to get the information we will need to review in order to take another look at your complaint. You will receive an answer from the Fidelis Chief Medical Officer within sixty (60) days. If we do not make a decision within 60 days, your request will be considered an adverse determination and be reviewed by using our internal appeal process. If we do not make a decision regarding your appeal within the required timeframes the initial denial will be reversed.
Utilization Review Appeals. (Expedited). Expedited or immediate appeals are available to the member, if he wants to appeal an adverse determination based upon medical necessity that involves:
i. Continued or extended healthcare services;
ii. Procedures, treatments or additional services for a member who is undergoing a course of continued treatment prescribed by his or her healthcare provider; or
iii. A situation where the member's healthcare provider believes an immediate appeal is needed. However, this does not apply in situations where we originally paid the member's claim before we had all the information needed. We will reach a decision with regard to the expedited appeal, within two (2) business days of the time we receive all the necessary information we need to conduct the appeal. We will notify you immediately of our decision by telephone. We'll send a written notice within two (2) business days of the decision. If you do not receive a satisfactory answer through our expedited appeals process, you may use the standard appeal process described above or apply to New York State for an external appeal.