APPEALS AND GRIEVANCES OF ADVERSE BENEFIT Sample Clauses

APPEALS AND GRIEVANCES OF ADVERSE BENEFIT. DETERMINATIONS 1. To file an Appeal or Grievance of an Adverse Benefit Determination, a Member, the Member's Representative or Health Care Provider acting on behalf of the Member, may contact the Plan at the address and telephone number located on the Member's ID Card; or submit a written request and any supporting record of medical documentation within 180 days of receipt of the written Notification of the Adverse Benefit Determination to the following: Mail Administrator ▇.▇. ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇ ▇▇▇- ▇▇▇-▇▇▇▇ The Health Advocacy Unit is available to assist the Member, the Member's Representative or Health Care Provider acting on behalf of the Member in both mediating and filing a Grievance or Appeal. See Section K for additional information. 2. a. A Member has the opportunity to submit written comments, documents, records, and other information relating to the Claim for Benefits;

APPEALS AND GRIEVANCES OF ADVERSE BENEFIT. DETERMINATIONS 1. To file an Appeal or Grievance of an Adverse Benefit Determination, a Member, the Member‟s Representative or Health Care Provider acting on behalf of the Member, may contact the Plan at the address and telephone number located on the Member‟s ID Card; or submit a written request and any supporting record of medical documentation within 180 days of receipt of the written Notification of the Adverse Benefit Determination to the following: [Mail Administrator

APPEALS AND GRIEVANCES OF ADVERSE BENEFIT. DETERMINATIONS 1. To file an Appeal or Grievance of an Adverse Benefit Determination, a Member, the Member’s Representative or Health Care Provider acting on behalf of the Member, may contact the Plan at the address and telephone number located on the Member’s ID Card; or submit a written request and any supporting record of medical documentation within 180 days of receipt of the written Notification of the Adverse Benefit Determination to the following: The Health Advocacy Unit is available to assist the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member in both mediating and filing a Grievance or Appeal. See Section K for additional information. a. A Member has the opportunity to submit written comments, documents, records, and other information relating to the Claim for Benefits; b. A Member shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information Relevant to the Member's Claim for Benefits; c. The Plan shall take into account all comments, documents, records, and other information submitted by the Member relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. 2. In addition to the requirements of paragraphs G.2.a through c herein, the following apply: a. The Plan shall provide for a review that does not afford deference to the initial Adverse Benefit Determination and will be conducted by an individual who is neither the individual who made the Adverse Benefit Determination that is the subject of the Appeal or Grievance, nor the subordinate of such individual; b. In deciding a Grievance of any Adverse Benefit Determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is Experimental/Investigational, or not Medically Necessary or appropriate, the Plan shall consult with a Health Care Provider with the same specialty as the treatment under review. c. Upon request, the Plan will identify medical or vocational experts whose advice was obtained on behalf of the Plan in connection with a Member's Adverse Benefit Determination, without regard to whether the advice was relied upon in making the benefit determination; d. A Health Care Provider engaged for purposes of a consultation under paragraph G.3.b herein shall be individuals who were neither consulted in connecti...