Health Care Insurer Appeals Process Information Packet ReliaStar Life Insurance Company
CAREFULLY READ THE INFORMATION IN THIS PACKET AND KEEP IT FOR FUTURE REFERENCE. IT HAS IMPROTANT INFORMATION ABOUT HOW TO APPEAL DECISIONS WE MAKE ABOUT YOUR HEALTH CARE.
Getting Information About the Health Care Appeals Process Help in Filing an Appeal: Standardized Forms and Consumer Assistance Form The Department of Insurance
We must send you a copy of this information packet when you first receive your policy, and within 5 business days after we receive your request for an appeal. When your insurance coverage is renewed, we must also send you a separate statement to remind you that you can request another copy of this packet. We will also send a copy of this packet to you or your treating provider at any time upon request. Just call our customer/member services number at (877) 527-6173 to ask.
At the back of this packet you will find forms you can use for your appeal. The Arizona Insurance Department (“the Department”) developed these forms to help people who want to file a health care appeal. You are not required to use them. We cannot reject your appeal if you do not use them. If you need help filing an appeal, or you have questions about the appeals process, you may call the Department’s Consumer Assistance Office at (602) 912-8444 or (800) 325-2548 or call us at (877) 527-6173.
How to Know When You Can Appeal
When we do not authorize or approve a service or pay for a claim, we must notify you of your right to appeal that decision. Your notice may come directly from us, or through your treating provider.
Decisions You Can Appeal
You can appeal the following decisions:
We do not pay for a service that you have already received.
We do not pay for a claim because we say that it is not “medically necessary.”
We do not pay for a claim because we say that it is not covered under your insurance
policy, and you believe it is covered.
Decisions You Cannot Appeal You cannot appeal the following decisions:
You disagree with our decision as to the amount of “usual and customary charges.”
You disagree with how we are coordinating benefits when you have health insurance with more than one insurer.
You disagree with how we have applied your claims or services to your plan deductible.
You disagree with the amount of coinsurance or copayments that you paid.
You disagree with our decision to issue or not issue a policy to you.
You are dissatisfied with any rate increases you may receive under your insurance policy.
You believe we have violated any other parts of the Arizona Insurance Code.
If you disagree with a decision that is not appealable according to this list, you may still file a complaint with the Arizona Department of Insurance, Consumer Affairs Division, 2910 N. 44th, Second Floor, Phoenix, AZ 85018.