WHEN YOU HAVE A COMPLAINT. You can call or write to us when you have a complaint about a benefit or coverage decision, Customer Service, or the quality or availability of a health care service. We recommend, but don't require, that you take advantage of this process when you have a concern about a benefit or coverage decision. There may be times when Customer Service will ask you to submit your complaint for review through the formal internal appeals process outlined below. We will review your complaint and notify you of the outcome and the reasons for our decision as soon as possible, but no later than 30 days from the date we received your complaint. WHEN YOU DO NOT AGREE WITH A PAYMENT OR BENEFIT DECISION If we declined to provide payment or benefits in whole or in part, and you disagree with that decision, you have the right to request that we review that adverse benefit determination through a formal, internal appeals process. This plan's appeals process will comply with any new requirements as necessary under state and federal laws and regulations. What is an adverse benefit determination? An adverse benefit determination means a decision to deny, reduce, terminate or a failure to provide or to make payment, in whole or in part for services. This includes: A member's or applicant's eligibility to be or stay enrolled in this plan or health insurance coverage A limitation on otherwise covered benefits A clinical review decision A decision that a service is experimental, investigational, not medically necessary or appropriate, or not effective. WHEN YOU HAVE AN APPEAL ABOUT ELIGIBILITY By federal law, if you enrolled through The Exchange they are responsible for all eligibility decisions, not us. If an adverse benefit determination involved member’s or applicant’s eligibility to be or stay enrolled in this plan, your appeal should be filed with The Exchange. Please contact The Exchange at 000-000-0000 (TTY/TTD 855-627- 9604) or xxx.xxxxxxxxxxxx.xxx for information on this process. If we receive an appeal from you, we will forward it to The Exchange. The Exchange is responsible for the internal Appeal process as well as the external review process.
