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Zenith -- Provider Appeal for Network Exclusion Policy

The Provider will be notified of Zenith’s

denied.

If

the

request

is

granted,

the

determination in Provider will be

writing if the

request

for hearing is

contacted to

set the

hearing date.

Hearings will be conducted using the following process.

Counsel are generally not present in the hearings, except to assist in monitoring the fairness of the process, as this is an informal process. If the Provider will have counsel present at the hearing, the Provider must notify Zenith of that in the request for hearing.

Hearing Panel

Matters set for hearing will be reviewed by the Provider Exclusion Committee (“PEC”). The PEC will be chaired by a designee of the Corporate Legal Department (the “PEC Chair”). The composition of the PEC will vary depending on the basis of the Exclusion decision and be selected by Zenith. In all situations, the Committee will include the PEC Chair. Voting members may not include any Zenith employee or individual that was involved in the original decision to Exclude the Provider.

All PEC panels shall be comprised of at least three and no more than five voting members as follows:

  • 1.

    If the basis of the Exclusion was clinical in nature, such as quality of care issues, the voting panel will be comprised of peer reviewers with appropriate clinical experience to review the issues and make a final determination.

  • 2.

    If the basis of the Exclusion was non-clinical in nature such as a persistent failure to follow Zenith business policies and procedures, the voting panel will be comprised of Zenith employees or external resources with appropriate experience to review the issues and make a final determination.

In either a clinical or non-clinical file, the PEC may confer with members of Zenith’s medical staff and/or other external physicians or other individuals deemed appropriate to review the issues raised by the Provider. All appeal hearing determinations must be supported by a majority of the PEC panel.

All external panel participants will be required to sign a confidentiality agreement prior to

participating on the panel. confidentiality.

Internal staff participating on the PEC panel will be bound by

Hearing Procedure:

  • 1.

    All hearing requests will be routed directly to Corporate Legal for handling and response. A copy of the hearing request will be sent to Zenith Provider Relations for logging into the appeal log.

  • 2.

    Corporate Legal will review the hearing request submission to determine if the request was received within the applicable time frame and whether the Provider meets the requirements for a hearing.

  • 3.

    If hearing requirements have been met, Provider Relations will summarize the appeal request, gather information included with the request and obtain any additional data reports or information required to review the appeal along with applicable historical Provider information.

Rev. 2-09

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