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Denial and Appeals

Denial Process

The Medical Management Department provides a consistent process for the clinical denial of authorization requests. The Medical Director reviews the authorization request for medical justification of healthcare services, relating to the diagnosis presented. The Medical Director will present alternative services to the requesting physician.

If the services are considered to be inappropriate, the services will be denied by the Medical Director. A certified written notification will be provided to the member and a copy sent to the physician within 48 hours of the determination of the denial. The denial notification will include appeal language along with the address for the appeals process.

Appeals Process

Members have the right to file an appeal if they disagree with any adverse decision made by the Health Plan Administrator. If they disagree with a decision, they can file an appeal asking for another review. Members and/or providers may initiate an appeal in writing or by telephone and have 30 days from time of receipt of denial to appeal by submit the reason for case review. If authorization has been denied due to lack of medical information, the physician will need to attach all supporting documentation to the written request.

When the validity of a members medical necessity is questioned, the review will be performed by an accredited, external independent review entity. The review entity will select a physician specialist or other provider who is an expert in the treatment of the member's medical condition and knowledgeable about the recommended treatment. Neither the client nor the member will choose or control the choice of physicians or other provider experts. The costs of the external, independent review will be borne by the client.

If the expert recommends providing the proposed treatment or service the recommendation will be binding. In the event that the expert does not approve the proposed treatment or services and the member does not accept the decision reached, the issue becomes a dispute and settlement of disputes is the responsibility of the client. The client shall make all final decisions with respect to disputed claims payments.  Coverage for the proposed service or treatment will be provided subject to the terms and conditions generally applicable to all other benefits under the member's Health Plan.