What is Clinical Appeals

Any  provider  may  appeal  an  unfavorable  decision  regarding  a  denial  of  a  Pre-Service Request  for  physician  services  or  denial  of  authorization  for  hospital  (emergency  room, observation, inpatient, or outpatient) services. There shall be a general appeals process for items  of  a  routine  nature,  and  an  expedited  appeals  process  for  items  of  an  urgent  or emergent nature. The final decision of whether to expedite the appeal will be made by the
Plan.

For clinical appeals, the provider will have sixty (60) days to appeal to the Plan from the date of the initial denial of the service. Thereafter, the Plan will have thirty (30) days to process the clinical appeal in which the following will occur:

• If there is no new medical documentation submitted or the information is inadequate, the appeal will be reviewed by an independent third party physician.

• If new medical documentation is submitted, the appeal will be reviewed by the Plan’s Medical  Director.  If  the  recommendation  of  the  Medical  Director  is  to  uphold  the decision, the appeal will be reviewed by an independent third party physician.

• If the request for service is for a non-covered benefit, or exhaustion of benefits, or the member is no longer covered under the Plan, the appeal will be reviewed by the Plan Administrator.

If the appeal (clinical denial) is overturned, a letter of approval and Treatment Authorization Form (TAF) will be faxed to the provider.

If the appeal (clinical denial) is upheld, a letter of denial will be faxed to the provider. Questions regarding clinical appeals may be directed to the Medical Management Appeals Coordinator by calling (863) 534-5384.

Claims Appeals
Providers  may  appeal  an  unfavorable  decision  regarding  a  denial  of  claims  payment.    For claims appeals, providers may initially appeal to the Plan for a first level appeal by faxing a completed  Claims  Appeal  form  to  the  Claims  Section  at  (863)  519-4711.  If  the  Appeals Coordinator of the Plan upholds its initial claims payment decision, the provider may appeal a second time for a second review and final determination by the Plan Administrator. Please refer to the Claims Section for more detailed information pertaining to the appeal of a claim. Questions  regarding  claim(s)  appeals  may  be  directed  to  the  Claims  Section  Appeals Coordinator by calling (863) 519-2086.