Internal Appeals Sample Clauses
Internal Appeals. 1. Filing an Internal Appeal If the Enrollee disagrees with the Contractor’s decision, the Enrollee may file an internal Appeal by writing, faxing, or calling the Contractor within 60 calendar days of the receipt of the written denial notice. The Enrollee must follow an oral filing with a written signed Appeal within the 60-day limit, unless the Enrollee requests an expedited appeal decision in accordance with Section 2.9.B.2.b. A Provider acting on behalf of an Enrollee, and with the Enrollee’s written consent, may file an internal Appeal. The Enrollee may also file an internal Appeal through the Social Security Administration or the Railroad Retirement Board, which will forward the Appeal to the Contractor. The 60-day limit may be extended at the discretion of the Contractor. Except for the circumstances described in Subsection 2.9(C)(2), an Enrollee must first exhaust the Contractor’s internal Appeal process under Subsection 2.9(B) before the Enrollee can proceed with an external Appeal under Subsection 2.9(C).
2. Making an Internal Appeal Decision As specified below, the Contractor must make an internal Appeal decision within appropriate timeframes. The Contractor must afford a reasonable opportunity for the Enrollee, or a designated representative, to present information orally or in writing during the internal Appeal process. The internal Appeal decision must be made by a physician who was not involved in the initial decision and who has appropriate expertise in the field of medicine for the services at issue. The Contractor must notify the Enrollee of its internal Appeal decision in writing and, for an expedited internal Appeal, the Contractor must also make reasonable efforts to provide oral notice.
Internal Appeals a. If a Member is not satisfied with any HDS adverse benefit determination, HDS payment, HDS decision, or other HDS action or omission related to the HDS Plan, Member may appeal by submitting a written request to the HDS employee designated as the HDS Appeals Manager. HDS must receive the appeal within one year from the date of the action, omission, or decision being contested. If the appeal concerns a benefit coverage or payment dispute, HDS must receive the appeal within one year from the date of the notice in which HDS first informed the Member or Subscriber of the denial or limitation on a claim for benefits. Requests that do not comply with the requirements of the appeals process will not be recognized or treated as an appeal by HDS.
b. To be recognized as an appeal, the appeal request must include
1) the name and telephone number of the person filing the appeal;
2) identification of the request as an "Appeal";
3) the date of HDS's contested decision, action, or omission;
4) the Member's name and ▇▇▇▇▇▇▇▇▇▇'s name;
5) the Member’s Subscriber number;
6) the Member’s mailing address and phone number;
7) the dentist's name and date of service if the appeal concerns a benefit coverage or payment dispute;
8) the HDS claim number;
9) a description of the facts related to the appeal and information to show why HDS was in error in its action, omission or decision;
Internal Appeals