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Medical Appeals If a participant believes that Blue Cross & Blue Shield incorrectly denied all or part of a claim, he has the right to obtain a full and fair review. A request for a review must be made in writing to Blue Cross & Blue Shield.

The participant has 60 days to request a review after receiving notice of denial from Blue Cross & Blue Shield. If the participant fails to request a review within this timeframe, the right to review is forfeited.

After the claim has been reviewed, if benefits are again denied, the decision will be sent to the participant in writing. The letter will include the reason(s) why benefits are denied, with reference to the Plan provisions on which the decision is based.

If, after following the appeal procedure described above, the participant still disagrees with the determination, a final appeal may be submitted in writing to the Department of Finance and Administration, Office of Insurance within 30 days of the second denial. The request to the Office of Insurance must include a copy of Blue Cross & Blue Shield’s review decision and all information pertinent to the claim. The decision of the Department of Finance and Administration, Office of Insurance is final and not subject to further consideration.

Failure to request a review within the above referenced time frames and in accordance with the procedures will result in the participant’s right to an appeal and rights to sue being forfeited.

Prescription Drug Appeals If a participant believes that Catalyst Rx incorrectly denied all or part of a prescription drug claim, he has the right to obtain a full and fair review. A request for review must be made in writing to Catalyst Rx.

The participant has 60 days from receiving notice of denial from Catalyst Rx to request a review. If the participant fails to request a review within this timeframe, the right to review is forfeited.

After the claim has been reviewed, if benefits are again denied, the decision will be sent to the participant in writing. The letter will include the reason(s) why benefits are denied, with reference to the Plan provisions of which the decision is based.

If, after following the appeal procedure described above, the participant still disagrees with the determination, a final appeal may be submitted in writing to the Department of Finance and Administration, Office of Insurance within 30 days of the second denial. The request to the Office of Insurance must include a copy of the Catalyst Rx review decision and all information pertinent to the claim. The decision of the Department of Finance and Administration, Office of Insurance is final and not subject to further consideration.

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