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 wa...
