Standard Appeals. A standard appeal is a verbal or written request to review an adverse determination. The review is conducted by a peer reviewer who was not involved in the original adverse determination nor is the subordinate of the peer making the original adverse determination. A standard appeal applies to non-urgent, pre-service or retrospective pre-claim requests. Local specialty providers and independent review organizations are review consultants who may be utilized in the appeal process. Standard appeals may be requested within one hundred eighty (180) days from the date of notice of the original adverse determination letter. A final determination following the standard appeal will be made within thirty (30) days of receipt of the request. To initiate a standard appeal:
Standard Appeals. You may file a formal written Appeal of an Adverse Benefit Determination with Coventry Health Care of Utah Grievances and Appeals Department. Any individual You designate as an authorized representative, including Your health care Provider, may also write an Appeal on Your behalf. A written Appeal must be filed no later than one-hundred eighty (180) calendar days from the date You received notification of the Adverse Benefit Determination. Coventry Health Care of Utah’s review of the Appeal will be based only on the information You provide, such as medical records. The Grievances and Appeals Department will investigate the issue, and submit the Appeal with all relevant information to the appropriate Appeals committee for review and determination. You or Your authorized representative may review the claim file and present information to the committee in writing or by telephone. None of the committee members will have been involved in the initial decision. The Appeals committee will notify You in writing of the decision within the following timeframes: Post Service Claims (services have already been obtained) – sixty (60) days from receipt of Your Appeal Pre Service Claims (services that have not been obtained) – thirty (30) days from receipt of Your Appeal If the Appeals committee intends to uphold the initial denial after reviewing the Appeal, Coventry Health Care of Utah will provide You with any new or additional information or rationale considered in the Appeal process. The information will be given to You as soon as possible, to allow You to respond prior to the date the committee’s final decision is due. Any additional information You choose to provide in response will be presented to the Appeals committee for a final decision.
Standard Appeals. Any decision made by EB ESP to deny, reduce or terminate a service or to deny payment for a service will be provided to you orally and in writing and will include an explanation of our reasons for the denial along with an explanation of your appeal rights. If you disagree with our decision, you or someone acting on your behalf can send an appeal request to our general mailing address: East Boston Health Center/Elder Service Plan 00 Xxxx Xxxxxx East Boston, MA 02128 Attention: Compliance Director Or the appeal request may be sent by FAX to the following FAX number: 000-000-0000. Be sure to address the FAX to EB ESP Compliance Director. If you need help with your appeal request, call your social worker or Center Director to ask for help.
Standard Appeals. 2.14.2.2.1. The Contractor’s Appeals process must include the following requirements:
Standard Appeals. Any decision made by ESP of HHSI to deny, reduce or terminate a service or to deny payment for a service will be provided to you orally and in writing and will include an explanation of our reasons for the denial along with an explanation of your appeal rights. If you disagree with our decision, you or someone acting on your behalf can send an appeal request to our general mailing address: Elder Service Plan of Harbor Health Services 0000 Xxxxxx Xxxxxx Mattapan, MA 02126 Attention: Director of Operations Or the appeal request may be sent by FAX to the following FAX number: 000-000-0000. Be sure to address the FAX to ESP of HHSI Operations Director. If you need help with your appeal request, call the Director of Operations at 617-533- 2400. As soon as we receive your appeal request, our Executive Director of ESP of HHSI will appoint an appropriately credentialed professional who was not involved in the original decision to review your appeal. You and/or your representative will have an opportunity to present information related to the appeal request, in person, as well as in writing. ESP of HHSI will make a decision about your standard appeal request within 30 days of the day on which we receive your request. The ESP of HHSI Executive Director will notify you or your representative of our decision in writing. ESP of HHSI will address your appeal in a confidential manner. During the appeals process, ESP of HHSI will continue to furnish you all the required services identified in your care plan as authorized by the Interdisciplinary Team. For a Medicaid participant, ESP of HHSI will continue to furnish the disputed services until a decision is made on the appeal request if the following conditions are met: ESP of HHSI is proposing to terminate or reduce services currently being furnished to you. The participant requests continuation with the understanding that he or she may be liable for the costs of the contested services if the determination is not made in his or her favor. If we agree with your request, ESP of HHSI will furnish the disputed service(s) as expeditiously as your health condition requires. If we decide that our original decision was correct, you have additional appeal rights called an “External Appeal.” The External Appeal process is explained later in this section of the Enrollment Agreement.
Standard Appeals. 2.11.3.5.1. The ICO’s Appeals process must include the following requirements:
