Common use of Formal Appeal Clause in Contracts

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  The Insured’s SHL Membership number; and  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department XX Xxx 00000 Xxx Xxxxx, XX 00000 Fax: 0-000-000-0000 SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, in writing, of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  Agreement of Coverage • The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  • The Insured’s SHL Membership number; and  • A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department XX Xxx 00000 Xxx Xxxxx, XX 00000 Fax: 0-000-000-0000 SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, in writing, of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  The Insured’s SHL Membership numbernumber ; and  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department XX Xxx 00000 Xxx Xxxxx, XX 00000 Fax: 0-000-000-0000 SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, in writing, of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  The Insured’s SHL Membership number; and  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department XX Xxx 00000 Xxx Xxxxx, XX 00000 Fax: 0-000-000-0000 Agreement of Coverage SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, in writing, of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  • The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  • The Insured’s SHL Membership numbernumber ; and  • A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department XX X.X. Xxx 00000 XX000-0000 Xxx Xxxxx, XX 00000 00000-0000 Fax: 0-000-000-0000 SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, informed in writing, writing of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by SHL for up to fifteenone

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  • The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  • The Insured’s SHL Membership numbernumber ; and  • A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department XX Xxx 00000 Xxx Xxxxx, XX 00000 Fax: 0-000-000-0000 SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, informed in writing, writing of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by SHL for up to fifteenthirty

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information: Agreement of Coverage  The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  The Insured’s SHL Membership number; and  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department XX Xxx 00000 Xxx Xxxxx, XX 00000 Fax: 0-000-000-0000 SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, in writing, of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  • The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  • The Insured’s SHL Membership number; and  • A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department XX Xxx 00000 Xxx Xxxxx, XX 00000 Fax: 0-000-000-0000 Agreement of Coverage SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, in writing, of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen