Post-Service Claim. An Adverse Benefit Determination has been rendered for a service that has already been provided. Pre-Service Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided. Urgent Care Services Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided, where the application of non-urgent care appeal timeframes could seriously jeopardize: • Your life or health or your unborn child’s; or • In the opinion of the treating physician, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. INTERNAL APPEAL You, or your Authorized Representative, or a treating Provider or facility may submit an appeal. If you need assistance in preparing the appeal, or in submitting an appeal verbally, you may contact Alliant for such assistance at (000) 000-0000. You may submit appeals to the following addresses, dependent upon the type of appeal: Claims Appeals: Alliant Health Plans PO BOX 1247 Dalton, GA 30722 Alliant Health Plans c/o Magellan Rx Management Medical Appeals Department 000 Xxxxx Xxxx Xxxxxx, Xxxxx 000 Xxxx Xxxx Xxxx, XX 00000 Magellan Rx Management Appeals Department PO BOX 1599 Maryland Heights, MO 63043 Medical Appeals (Level I & II): Pharmacy Appeals (Level I & II): If you are Hearing impaired, you may also contact Alliant via the National Relay Service at 711. You (or your Authorized Representatives) must file an appeal within 180 days from the date of the notice of Adverse Benefit Determination. SPANISH (Español): Para obtener asistencia en Español, llame al (000) 000-0000. Within five business days of receiving an appeal (or 24 hours for appeals involving an Urgent Care Services Claim), Alliant will contact you (or your Authorized Representative) in writing or by telephone to inform you of any failure to follow Alliant’s internal appeal procedures. The appeal will be reviewed by personnel who were not involved in the making of the Adverse Benefit Determination and will include input from health care professional in the same or similar specialty as typically manages the type of medical service under review. TIMEFRAME FOR ALLIANT TO RESPOND TO APPEAL REQUEST TYPES TIMEFRAME FOR DECISION EXPEDITED APPEALS WITHIN 72 HOURS OR 3 CALENDAR DAYS PRE-SERVICE APPEALS (LEVEL I & II) WITHIN 15 DAYS POST-SERVICE APPEALS (LEVEL I & II) WITHIN 30 DAYS EXHAUSTION OF PROCESS The foregoing procedures and process are mandat...
Post-Service Claim within 60 calendar days after receipt of the claimant’s request for internal appeal.
Post-Service Claim. A post-service claim is a claim that does not require pre-approval as a condition of coverage. Approval or denial of an initial post-service claim will be sent to a claimant within 30 calendar days after receipt of the claim, unless an extension is required. The 30-day period may be extended once up to 15 calendar days. If the extension is required due to a claimant's failure to provide the necessary information, the Claims Administrator will describe the required information. A claimant will have at least 45 calendar days from receipt of the notice to provide the information.
Post-Service Claim. An Adverse Benefit Determination has been rendered for a service that has already been provided. Pre-Service Claim An Adverse Benefit Determination was rendered, and the requested service has not been provided.
Post-Service Claim. A claim for a benefit that is not a pre-service claim. Within 30 days of HMO’s receipt of the information reasonably necessary to make decision. Within 30 calendar days in writing. COMPLAINTS AND APPEALS HMO has procedures for Members to use if they are dissatisfied with a decision that the HMO has made or with the operation of the HMO. The procedure the Member needs to follow will depend on the type of issue or problem the Member has. • Appeal. An Appeal is a request to the HMO to reconsider an adverse benefit determination. The Appeal procedure for an adverse benefit determination has one level. An Appeal is a type of Complaint. If the Member is appealing a Disputed Health Care Service, the Member has the right to independent medical review in addition to the processes described in the Complaints and Appeals Section. • Complaint. A Complaint is a written or oral expression of dissatisfaction regarding the HMO or the operation of the HMO and/or a Provider including quality of care concerns, and includes a grievance, dispute, request for reconsideration or Appeal made by an enrollee or the enrollee’s representative.
Post-Service Claim. A Post-Service Claim is a claim for benefits that is filed after medical services or treatment is provided. A Post-Service claim may include Pre-Service Claims or Urgent-Care Claims where the medical services or treatment that was the subject of the Pre-Service Claim or Urgent-Care Claim has been provided and the only remaining issue with respect to such claim is the payment for the medical services or treatment.
Post-Service Claim. The Corporation will decide the appeal within a reasonable period of time but no later than thirty (30) days after receipt of the appeal. If the Member disagrees with the Corporation’s decision, the Member can submit a second appeal within ninety (90) days after receipt of the final decision of the first appeal. The Corporation will decide the second appeal within a reasonable period of time but no later than thirty (30) days after receipt of the second appeal.
