Member Services Representative. An employee of SHL that is assigned to assist the Insured or the Insured’s Authorized Representative in appealing an Adverse Benefit Determination.
Member Services Representative. An employee of HPN that is assigned to assist the Member or the Member’s Authorized Representative in appealing an Adverse Benefit Determination.
Member Services Representative. An employee who works under the general supervision of the Office Manager. These duties include, but are not limited to: credit aging and records, telephone answering service, filing, bookkeeping, accounting procedures, payroll, work orders, reports of all kinds, accounts payable, customer services of all types such as receiving payments from customers, collection calls, receipt stubs, etc., operates adding machines, calculators, typewriters, billing machines, addressing machines, postage mailing machines, handles customer complaints in such a manner that proper customer relationship is maintained, and performs such other bargaining unit work a assigned.
Member Services Representative. An employee of SHL that is assigned to assist the Insured or the Insured’s Authorized Representative in appealing an Adverse Benefit Determination. 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 X.X. Xxx 00000 Xxx Xxxxx, XX 00000-0000 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 (15) days, provided that the extension is necessary due to matters beyond the control of SHL and SHL notifies the Insured prior to the expiration of the initial thirty (30) day period of the circumstances requiring the extension and the date by which SHL expects to render a decision. If the extension is necessary due to a failure of the Insured to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information and the Insured shall be afforded at least forty-five (45) days from receipt of the notice to provide the information. If the Formal Appeal results in an Adverse Benefit Determination, the Insured will be informed in writing of the following: The specific reason or reasons for upholding the Adverse Benefit Determination; Reference to the specific Plan provisions on which the determination is based; A statement that the Insu...
