Problems - Appeals Process Summary

	BC/BS	Connecti Care	PHS	MedSpan	CIGNA	Aetna /USHC	Oxford
Note:	Can Appeal non-covered benefits	Excluded benefit denials handled by exclusion verification review process	Excluded and non-covered denials can be appealed	Complaint-any member expression of dissatisfaction with previous decision Appeal- a 2nd or 3rd member request to change previous decision	One year limit from date of last denial letter to submit an appeal	Grievance defined as a "complaint" made in writing that may or may not require specific corrective action.	Complaint defined as oral or written expression of dissatisfaction. Separate review of UR and Non-UR 2nd level appeals.
Review levels	1st Level complaint -Initiated verbally, electronically or written request within 60 days of denial -Response to member within 30 days of receipt of required documentation	1st Level complaint -Initiated verbally, electronically or written request within 1 year after denial -Receipt of appeal within 5 business days -Decision within 30 calendar days of appeal request	Separate appeal programs for medical necessity decisions and more general concerns. -Medical Necessity Appeal - Initiated verbally, electronic or written request within 60 days of denial -Reviewed by a Medical Director; notified within 30 days of receipt of pertinent information	1st Level complaint -Initiated by telephone or in writing. Representative attempts to resolve problem during initial call. If in writing, decision in writing within 10 business days. If additional information needed, decision within 10 business days of receipt of requested information	Separate appeals processes- Medical Necessity Appeal or Administrative Appeal. Level 1 Medical Necessity "complaint" -Initiated verbally or in writing. - Decision within 30 calendar days after receiving documentation -Extension can be requested up to 30th day for information gathering -Notification of decision within 2 business days	1stLevel Appeal – Member request for administrative service including claims review, denials, cancellations & quality of services provided.	1st Level Appeal –Received via phone are logged and attempt to resolve by Customer Service. If not, refer to appropriate dept. -Written complaints are acknowledged within 5 business days -Investigation and notification of decision within 10 business days from receipt of complaint.
	2nd Level Appeal -Written request if utilization review situation -Initiated within 60 days of complaint denial -Response within 30 days from date all information is received	2nd Level Appeal -Within 6 months after denial 1st level appeal -Reviewed by Member Appeals Committee (non-medical denials) or Medical Appeals Panel (medical necessity) -Decision within 30 days of request; if more information required, decision within 45 business days of request	Grievance (reconsideration) process for issues of non-medical necessity-call to member; if member still dissatisfied, written grievance filed up to 6 months from date of event -Grievances reported to member within 30 days of receipt of necessary information	2nd Level Appeal -Initiated in writing or electronically. Requests reviewed by Level 2 Grievance Committee, which meets bi-weekly -Member notified within 15 business days after acknowledgment of request -If additional information required, determination made within 15 business days of receipt	2nd Level Appeal -Initiated verbally or in writing -Reviewed by Committee including physician within 30 days of request -No extension allowed. -Notification of decision within 5 business days	2nd Level Appeal -Reviewed by Grievance Committee -Decision within 30 days of receipt unless additional information is not as yet received -Written notice within 10 business days of decision -Member may appeal in writing within 30 days of notice	2nd Level Appeal -Non-UM Appeals-request to change previous decision-acknowledgement of appeal within 5 business days; disposition within 30 days. Before end of 30 days, plan may notify member of additional 15 days needed to resolve appeal. - UM Appeal – request to change decision concerning medical necessity or life threatening condition. Acknowledgement within 5 business days from receipt of appeal. Review by a physician; notification of disposition within 30 days from receipt of additional information.
	3rd Level Appeal -Written request if utilization review situation -Decision made within 60 days of notice of denial of appeal -Response within 30 days from date all information is received			3rd Level Appeal -Initiated in writing and reviewed by Level 3 Grievance Committee which meets monthly -Member can attend and permitted to bring attorney -Determination within 45 business days of receipt of additional information	Level 1-Admin Appeal-"complaint"-reviewed & decision within 30 calendar days. Notification of decision within 2 business days. Level 2-Admin Appeal-"grievance"-reviewed by committee, member may attend. Meeting within 60 days of original request for Level 1 appeal or 30 days from request for Level 2 appeal. Notification of decision within 5 business days of meeting.	3rd Level Appeal – Reviewed by Grievance Appeal Committee which considers all appeals filed 7 business days or more in advance of hearing day. Member and/or physician or attorney can attend. Written decision within 30 working days of conclusion of appeal hearing.	3rd Level Appeal – UM&Non-UM Appeals – request to change previous decision; acknowledgement letter within 5 business days from receipt of appeal. Review conducted by practicing physician. Written notification within 5 working days but no later than 30 days from receipt of appeal.
Emergency or life-threatening situation	Determination within 1 business day of appeal and all information is received.	Decision within 2 business days of appeal and all information is received.	Decision within 2 business days of appeal and all information is received.	Decision within 2 business days of appeal and all information is received.	Level 1 Expedited Decision: within 2 business days of necessary information. Level 2 decision within 72 hours based on info available.	Urgent Care: Request action within 15 days from denial. Medical Director reviews within 48 hours. Emergent Care: Medical Director reviews, decision within 96 hours of receipt. Adverse decision reviewed by Regional Medical Director immediately.	Decision within 2 business days from receipt of all necessary information.
	External Appeals Process-State of CT Insurance Dept.	External Appeals Process-State of CT Insurance Dept.	External Appeals Process– State of CT Insurance Dept.	External Appeals Process- State of CT Insurance Dept.	External Appeals Process-State of CT Insurance Dept.	External Appeals Process-State of CT Insurance Dept.	External Appeals Process - State of CT Insurance Dept.

Content Last Modified on 5/30/2007 2:53:59 PM