Asking us to Reconsider a Decision
We understand that you may disagree with a decision that we make. We make decisions about resolving complaints and we make decisions about authorizing coverage for care or treatment. When we make these decisions, we make every effort to avoid disagreements. If you do not agree with our decision, you may appeal.
We will tell you about how to appeal decisions we make as part of the resolution process. This includes how to appeal our decisions that might have a negative impact on your coverage or benefits or our relationship. An appeal is your request to us to change our decision about a complaint resolution or coverage for care or treatment issue. If you are unhappy with the decision, please contact us.
If you need language assistance to help you file an appeal, please let us know. We will provide language assistance at no cost to you. Finding the best way to resolve your appeal is an important part of our quality improvement program, and we will investigate the issues thoroughly.
The team involved in the investigation will not be the same as the individuals who made the first decision. We determine the best team to investigate an appeal based on the nature of the appeal. When appeals are of a clinical nature, an appeal reviewer (who is a clinician and who was not involved in the original decision) investigates the issues and proposes a resolution.
We propose resolutions to routine appeals within 30 calendar days and notify you of the decision. We propose resolutions to clinically urgent appeals within 72 hours and notify you of the decision. For appeals of proposed complaint resolutions, the appeal decision is final and there is no second level of appeal.