Non-Acute Care Services Appeals Sample Clauses

Non-Acute Care Services Appeals. If your request for pre-certification of non-acute care services is wholly or partially denied and you have not received such non-acute care services or if you are currently receiving non-acute care services and a request for the extension of these services is wholly or partially denied, you or your authorized representative may submit an appeal of that denial within 180 calendar days after receiving notice that your request was denied. Your appeal can be submitted to PIC in writing, by telephone, or electronically, along with any issues, comments, and additional information, as appropriate. You have the right to present written evidence and telephonic testimony as part of the appeals process. When you appeal the initial determination for medical reasons, XXX will arrange for review of the clinical material by a physician who holds a current, unrestricted license to practice medicine, has the same or similar medical specialty as a provider that typically treats or manages the condition for which pre-certification of non-acute care services was requested and who did not make the initial determination. Within 15 calendar days after your appeal is received by PIC, you, and your attending health care professional will receive written notice of PIC’s decision, including the specific reasons for it and the procedure for requesting an external review to the extent external review is required by law. This time period may be extended for up to an additional four calendar days if you agree.
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Non-Acute Care Services Appeals. If your request for pre-certification of non-acute care services is wholly or partially denied and you have not received such non-acute care services or if you are currently receiving non-acute care services and a request for the extension of these services is wholly or partially denied, you or your authorized representative may submit an appeal of that denial within 180 calendar days after receiving notice that your request was denied. Your appeal can be submitted to PIC in writing, by telephone, or electronically, along with any issues, comments, and additional information, as appropriate. You have the right to present written evidence and telephonic testimony as part of the appeals process. When you appeal the initial determination for medical reasons, XXX will arrange for review of the clinical material by a physician in the same or similar specialty who did not make the initial determination. Within 30 calendar days after your appeal is received by PIC, you, your attending health care professional and your attending provider will receive written notice of PIC’s decision, including the specific reasons for it and the procedure for requesting an external review to the extent external review is required by law. This time period may be extended for up to an additional 14 calendar days if you agree.
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