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Zenith -- Provider Appeal for Network Exclusion Policy

Appeal Decisions

Zenith will conduct a review of the file and all applicable information and records and will take one of the following actions within 30 calendar days of receipt of the Provider appeal:

  • 1.

    request additional pertinent information or clarifications (upon receipt of such information or clarifications, the 30 calendar day review period begins anew; if the requested information is not received within 20 working days, Zenith will deny the appeal for lack of response and information); or

  • 2.

    issue a written opinion based on the submitted written materials and Zenith file materials.

The appeal determination will be based on the materials provided by the Provider and any records, information or data obtained by, produced by or in the possession of Zenith at the time the determination is rendered as well as information obtained through verbal communications between the Provider or the Provider’s designated representative(s) and Zenith.

Zenith will send the Provider written notification of its determination, including:

  • 1.

    who made the determination; and

  • 2.

    the rationale for the determination.

Decisions will be made by appropriate internal staff or external consultants. If the Provider subsequently obtains new information that was not considered by Zenith as part of the written appeal, the Provider may request reconsideration of the appeal determination by submitting the new information to Zenith within 30 days of the date the provider first becomes aware of the new

information. appeals and

The request must be sent in writing to the address set out above for hearing requests. “New information” means information that did not exist

written or was

unknown to the considerations as


at the

part of the


time the Provider and determination.






Submission of Hearing Request on Appeal Determination

A Provider may dispute Zenith’s appeal decision by requesting a hearing.

Hearing requests

must be made within 30 days of the date the Provider receives the written appeal determination. A hearing will be granted only if the Provider has fully complied with the written appeal process and the Provider submits evidence showing that Zenith’s exclusion of the Provider from the

Zenith Network would:

  • 1.

    significantly impair the ability of an ordinary, competent Provider to practice medicine or a medicine specialty in the Excluded Provider’s particular geographic area, and

  • 2.

    that exclusion from the Network affects a substantial economic interest of the Excluded Provider.

Zenith will make a determination on the request for hearing within 30 days of the date the r e q u e s t i s r e c e i v e d b y Z e n i t h . I f t h e P r o v i d e r m e e t s t h e h e a r i n g c r i t e r i a , a h e a r i n g w i l l b e Otherwise, the request for hearing will be denied and the original appeal scheduled.

determination will stand. Hearings will be held telephonically unless the Provider requests an in person hearing. If the Provider requests an in person hearing, the hearing will be held in the Zenith regional office nearest the Provider or at another location selected by Zenith.

Rev. 2-09

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