Internal Grievance Process Clause Samples

Internal Grievance Process. Under the law, you must exhaust our internal grievance process before you, your representative, or your health care provider file a complaint with the Insurance Commissioner, unless the adverse decision involves an emergency case for which services have not already been rendered, or is described above under Complaints, or unless it is under one of the other circumstances outlined below. For retrospective denials (denials on health services which have already been rendered), a compelling reason may not be shown. If the adverse decision by us involves a compelling reason for which services have not been rendered, you, your representative, or your health care provider may address your complaint directly to the Insurance Commissioner without first directing it to us. We will not make an adverse decision retrospectively regarding preauthorized or approved Covered Health Care Services delivered to a Covered Person, unless such preauthorization or approval was based on fraudulent, intentionally misrepresented, or omitted information. Such omitted information must have been critical requested information regarding the Covered Health Care Services whereby the preauthorization or approval for such Covered Health Care Services would not have been approved if the requested information had been received. For non-emergency cases, if we render an adverse decision, a notice of this adverse decision will be communicated to you, your representative, or your health care provider either: • Orally by telephone; or • With your, you representative or your health care provider’s consent, by text, facsimile, e-mail, online portal, or other expedited means. We will document the adverse decision in writing after we have provided the verbal communication of the adverse decision as described above. Written notification of the adverse decision will be sent to you, your representative, and your health care provider within five working days after the adverse decision has been made. For emergency case adverse decisions timeframes, see below under the provision entitled Expedited Review in Emergency Cases. The adverse decision will be accompanied by a Notice of Adverse Decision attachment. This Notice will include the following information: • Details concerning the specific factual basis for the denial in clear, understandable language; • The specific criteria or guidelines on which the decision is based; • The name, business address and direct telephone number of the Medical Director who ...