Common use of WHEN YOU HAVE A COMPLAINT Clause in Contracts

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.

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.

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- 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.

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. WHEN YOU HAVE AN APPEAL After you find out about an adverse benefit decision, you can ask for an internal appeal. Your plan has one internal appeal level. Your internal appeal will be reviewed by people who were not involved in the initial adverse benefit determination. If the adverse benefit determination involved medical judgment, the review will be done by a provider. They will review all of the information about your appeal and will give you a written decision. If you are not satisfied with the decision, you may ask for an external review. This is described below. Who may file an internal appeal You may file an appeal for yourself. You can also appoint someone to do it for you. This can be your doctor or provider. To appoint a representative, you must sign an authorization form and send it to us. The address and fax number are listed on the back cover. This release gives us your approval for this person to appeal on your behalf and allows our release of information, if any, to them. If you appoint someone else to act for you, that person can do any of the tasks listed below in this booklet that you would need to do. Please call us for an Authorization For Release form. You can also get a copy of this form on our website at xxxxxxx.xxx. How to file an internal appeal You may file an appeal by calling Customer Service or by writing to us at the address listed on the back cover. We must receive your internal appeal request within 180 calendar days of the date you were notified of the adverse benefit determination. You may send your written appeal request to the address or fax number on the back cover. If you need help filing an appeal, or would like a copy of the appeals process, please call Customer Service at the number listed on the back cover. You can also get a description of the appeals process by visiting our website at xxxxxxx.xxx. We will confirm in writing that we have your request within 72 hours. What if my situation is clinically urgent? If your provider believes that your situation is urgent under law, we will expedite your appeal; for example:  Your doctor thinks a delay may put your life or health in serious jeopardy or would subject you to pain that you cannot tolerate  The appeal is related to inpatient or emergency services and you are still in the emergency room or in the ambulance We will not expedite your appeal if you have already received the services you are appealing, or if you do not meet the above requirements. Please call Customer Service if you want to expedite your appeal. The number is listed on the back cover. If your situation is clinically urgent, you may also ask for an expedited external review at the same time you request an expedited internal appeal. Can I provide more information for my appeal? You may give us more information to support your appeal either at the time you file an appeal or at a later date. Mail or fax the information to the address and fax number listed on the back cover. Please give us this information as soon as you can. Can I get copies of information relevant to my appeal? We will also send you any new or additional information we considered, relied upon or generated in connection to your appeal. We will send it as soon as possible and free of charge. You will have the chance to review it and respond to us before we make our decision. What happens next? We will review your appeal and give you a written decision within the time limits below:  For expedited appeals, as soon as possible, but no later than 72 hours after we got your request. We will call, fax or email and then follow up in writing.  For appeals for benefit decisions made before you received the services, within 14 days of the date we got your request.  For appeals of experimental and investigational denials, within 20 days. Only with your informed consent may the review period be extended.  For all other appeals, within 14 days of the date we got your request. If we need more time to review your request, we may extend the review to no more than 30 days, unless we ask for and receive your agreement for more time after the 30 days. We will send you a notice (see Notice) of our decision and the reasons for it. If we uphold our initial decision, we will tell you about your right to an external review at the end of the internal appeals process. You can also go to the next appeal step if we do not comply with the rules above when we handle your appeal. Appeals about ongoing care If you appeal a decision to change, reduce or end coverage of ongoing care because the service is no longer medically necessary or appropriate, we will suspend our denial of benefits during the appeal period. Our provision of benefits for services received during the internal appeal period does not, and should not be assumed to, reverse our denial. If our decision is upheld, you must repay us all amounts that we paid for such services. You will also be responsible for any difference between our allowed amount and the provider's billed charge if the provider is non-contracting.

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 000855-000923-0000 4633 (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.

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. WHEN YOU HAVE AN APPEAL After you find out about an adverse benefit decision, you can ask for an internal appeal. Your plan has one internal appeal level. Your internal appeal will be reviewed by people who were not involved in the initial adverse benefit determination. If the adverse benefit determination involved medical judgment, the review will be done by a provider. They will review all of the information about your appeal and will give you a written decision. If you are not satisfied with the decision, you may ask for an external review. This is described below. Who may file an internal appeal You may file an appeal for yourself. You can also appoint someone to do it for you. This can be your doctor or provider. To appoint a representative, you must sign an authorization form and send it to us. The address and fax number are listed on the back cover. This release gives us your approval for this person to appeal on your behalf and allows our release of information, if any, to them. If you appoint someone else to act for you, that person can do any of the tasks listed below in this booklet that you would need to do. Please call us for an Authorization For Release form. You can also get a copy of this form on our website at xxxxxxxxxx.xxx. How to file an internal appeal You may file an appeal by calling Customer Service or by writing to us at the address listed on the back cover. We must receive your internal appeal request within 180 calendar days of the date you were notified of the adverse benefit determination. You may send your written appeal request to the address or fax number on the back cover. If you need help filing an appeal, or would like a copy of the appeals process, please call Customer Service at the number listed on the back cover. You can also get a description of the appeals process by visiting our website at xxxxxxxxxx.xxx. We will confirm in writing that we have your request within 72 hours. What if my situation is clinically urgent? If your provider believes that your situation is urgent under law, we will expedite your appeal; for example:  Your doctor thinks a delay may put your life or health in serious jeopardy or would subject you to pain that you cannot tolerate  The appeal is related to inpatient or emergency services and you are still in the emergency room or in the ambulance We will not expedite your appeal if you have already received the services you are appealing, or if you do not meet the above requirements. Please call Customer Service if you want to expedite your appeal. The number is listed on the back cover. If your situation is clinically urgent, you may also ask for an expedited external review at the same time you request an expedited internal appeal. Can I provide more information for my appeal? You may give us more information to support your appeal either at the time you file an appeal or at a later date. Mail or fax the information to the address and fax number listed on the back cover. Please give us this information as soon as you can. Can I get copies of information relevant to my appeal? We will also send you any new or additional information we considered, relied upon or generated in connection to your appeal. We will send it as soon as possible and free of charge. You will have the chance to review it and respond to us before we make our decision. What happens next? We will review your appeal and give you a written decision within the time limits below:  For expedited appeals, as soon as possible, but no later than 72 hours after we got your request. We will call, fax or email and then follow up in writing.  For appeals for benefit decisions made before you received the services, within 14 days of the date we got your request.  For all other appeals, including experimental and investigational appeals, within 14 days of the date we got your request. If we need more time to review your request, we may extend the review to no more than 30 days, unless we ask for and receive your agreement for more time after the 30 days. We will send you a notice (see Notice) of our decision and the reasons for it. If we uphold our initial decision, we will tell you about your right to an external review at the end of the internal appeals process. You can also go to the next appeal step if we do not comply with the rules above when we handle your appeal. Appeals about ongoing care If you appeal a decision to change, reduce or end coverage of ongoing care because the service is no longer medically necessary or appropriate, we will suspend our denial of benefits during the appeal period. Our provision of benefits for services received during the internal appeal period does not, and should not be assumed to, reverse our denial. If our decision is upheld, you must repay us all amounts that we paid for such services. You will also be responsible for any difference between our allowed amount and the provider's billed charge if the provider is non-contracting.

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- 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.