An Appeal Sample Clauses

An Appeal. (C) A request for an External Appeal. In each of these review processes, Your notice to Us is considered to be filed on the date We first receive it orally or in writing. Detailed information on how to submit all of the above may be found in this Contract, on Our website, in newsletters, and in medical management determination letters sent to Enrollees when a Health Service is denied. At least annually in a newsletter, We notify Enrollees about the Grievance and Appeal process and the availability of External Appeals. Neither You nor Your Designated Representative will be subject to retaliation from Us for exercising Your rights to any of the review processes described in this Article. Also, We may not take any action against a Provider solely on the basis that the Provider represents You in any of the review processes described in this Article.

An Appeal. You can ask us to re-review an adverse benefit determination. This is called an appeal. You can appeal to us by calling the toll-free number on your ID card. Appeals of adverse benefit determinations You can appeal our adverse benefit determination. We will assign your appeal to someone who was not involved in making the original decision. You must file an appeal within 180 calendar days from the time you receive the notice of an adverse benefit determination. You can appeal by sending a written appeal to the address on the notice of adverse benefit determination, by calling the toll-free number on your ID card. You need to include:  Your name  Your employer’s name  A copy of the adverse benefit determination  Your reasons for making the appeal  Any other information you would like us to consider Another person may submit an appeal for you, including a provider. That person is called an authorized representative. You need to tell us if you choose to have someone else appeal for you (even if it is your provider). You should fill out an authorized representative form telling us that you are allowing someone to appeal for you. You can get this form on our website or by calling the toll-free number on your ID card. You can use an authorized representative at any level of appeal. You can appeal two times under this plan. If you appeal a second time you must present your appeal within 60 calendar days from the date you receive the notice of the first appeal decision. Urgent care or pre-service claim appeals If your claim is an urgent claim or a pre-service claim, your provider may appeal for you without having to fill out a form. We will provide you with any new or additional information that we used or that was developed by us to review your claim. We will provide this information at no cost to you before we give you a decision at your last available level of appeal. This decision is called the final adverse benefit determination. You can respond to this information before we tell you what our final decision is. Timeframes for deciding appeals The amount of time that we have to tell you about our decision on an appeal claim depends on the type of claim. The chart below shows a timetable view of the different types of claims and how much time we have to tell you about our decision. Type of notice Urgent care claim Pre-service claim Post-service claim Concurrent care claim Appeal determinations at each level (us) 36 hours 15 days 30 days As appropriate to ty...