Failure to request a review within the above referenced time frame and in accordance with the procedures will result in the participant’s right to an appeal and rights to sue being forfeited.
Utilization Review Appeals If a participant or provider believes that Intracorp incorrectly denied all or part of a medical service, he may initiate the appeals process. The chart below outlines the process.
The attending physician contacts Intracorp to discuss any findings of “not medically necessary”. Based on that discussion, a second Intracorp staff physician will determine whether the original decision should be affirmed or amended. The enrollee and attending physician will be notified in writing of the results of this review.
When a disagreement between the attending physician and the Intracorp staff physician is not resolved as a result of Step 1, the patient/enrollee or the attending physician must submit to Intracorp a written request for review, outlining the reason for the request. A thorough review and discussion of medical records and other supporting documentation will be undertaken. Based on this review, a decision affirming or amending the original decision will be rendered and provided in writing to the enrollee and the attending physician.
If the attending physician or the patient/enrollee is not satisfied with the outcome of Step 2, either of them may request an independent review by an independent physician under contract with Intracorp to conduct such reviews. The decision of the independent physician is final and not subject to further reconsideration.
Failure to request a review in accordance with the procedures above will result in the participant’s right to an appeal and rights to sue being forfeited.
Out-of-network reviews are not subject to the utilization review appeals process. A denial of an out-of-network approval may be appealed directly to the Department of Finance and Administration, Office of Insurance.
Other Complaints If a participant has a complaint regarding service provided by Blue Cross & Blue Shield, Catalyst Rx, the AHS State Network, or Intracorp, he may write to the Office of Insurance. The letter should contain specific information about the complaint.