Common use of Formal Appeal Clause in Contracts

Formal Appeal. A Formal Appeal must be submitted orally or in writing to HPN’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 Member’s name (or name of Member and Member’s Authorized Representative), address, and telephone number;  The Member’s HPN membership number ; and  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Member feels that the Adverse Benefit Determination was wrong. Additionally, the Member may submit any supporting medical records, Physician’s letters, or other information that explains why HPN should approve the Claim for Benefits. The Member 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: Health Plan of Nevada, Inc. Attn: Customer Response and Resolution Department PO Box 14865 Las Vegas, NV 89114 Fax: 0-000-000-0000 HPN will investigate the appeal. When the investigation is complete, the Member 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 HPN for up to fifteen

Formal Appeal. A Formal Appeal must be submitted orally or in writing to HPN’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 Member’s name (or name of Member and Member’s Authorized Representative), address, and telephone number;  • The Member’s HPN membership number ; and  • A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Member feels that the Adverse Benefit Determination was wrong. Additionally, the Member may submit any supporting medical records, Physician’s letters, or other information that explains why HPN should approve the Claim for Benefits. The Member 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: Health Plan of Nevada, Inc. Attn: Customer Response and Resolution Department PO Box 14865 Las Vegas, NV 89114 Fax: 0-000-000-0000 HPN will investigate the appeal. When the investigation is complete, the Member 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 HPN for up to fifteen

Formal Appeal. A Formal Appeal must be submitted orally or in writing to HPN’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 Member’s name (or name of Member and Member’s Authorized Representative), address, and telephone number;  The Member’s HPN membership number ; and  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Member feels that the Adverse Benefit Determination was wrong. Additionally, the Member may submit any supporting medical records, Physician’s letters, or other information that explains why HPN should approve the Claim for Benefits. The Member 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: Health Plan of Nevada, Inc. Attn: Customer Response and Resolution Department PO Box 14865 Las Vegas, NV 89114 Fax: 0-000-000-0000 HPN will investigate the appeal. When the investigation is complete, the Member 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 HPN for up to fifteenthirty

Formal Appeal. A Formal Appeal must be submitted orally or in writing to HPN’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 Member’s name (or name of Member and Member’s Authorized Representative), address, and telephone number;  The Member’s HPN membership number ; and  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Member feels that the Adverse Benefit Determination was wrong. Additionally, the Member may submit any supporting medical records, Physician’s letters, or other information that explains why HPN should approve the Claim for Benefits. The Member 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: Health Plan of Nevada, Inc. Attn: Customer Response and Resolution Department PO Box 14865 Las Vegas, NV 89114 Fax: 0-000-000-0000 Agreement of Coverage HPN will investigate the appeal. When the investigation is complete, the Member 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 HPN for up to fifteen

Formal Appeal. A Formal Appeal must be submitted orally or in writing to HPN’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 Member’s name (or name of Member and Member’s Authorized Representative), address, and telephone number;  The Member’s HPN membership number ; and  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Member feels that the Adverse Benefit Determination was wrong. Additionally, the Member may submit any supporting medical records, Physician’s letters, or other information that explains why HPN should approve the Claim for Benefits. The Member 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: Agreement of Coverage Health Plan of Nevada, Inc. Attn: Customer Response and Resolution Department PO Box 14865 Las Vegas, NV 89114 Fax: 0-000-000-0000 HPN will investigate the appeal. When the investigation is complete, the Member 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 HPN for up to fifteen