Who Can File An Appeal? Either you or your treating provider can file an appeal on your behalf. At the end of this packet is a form that you may use for filing your appeal. You are not required to use this form, and can send us a letter with the same information. If you decide to appeal our decision to deny authorization for a service, you should tell your treating provider so the provider can help you with the information you need to present your case.
Description of the Appeals Process
The standard appeals process has 3 levels:
Level 1 Level 2 Level 3
Informal Reconsideration* Formal Appeal External Independent Medical Review
We make the decisions at Level 1 and Level 2. An outside reviewer, who is completely independent from our company, makes Level 3 decisions. You are not responsible to pay the costs of the external review if you choose to appeal at Level 3.
*Informal reconsideration is not available for a denied claim. Therefore, since we do not require preauthorization of services and any action is taken only after submission of a claim, we do not provide for a Level 1 appeal. All appeals will begin at Level 2 - Formal Review.
STANDARD APPEAL PROCESS FOR DENIED CLAIMS
Level 1. Informal Reconsideration
Not applicable. All appeals will begin at Level 2 - Formal Appeal.
Level 2. Formal Appeal
Your request: You may request Formal Appeal if you have an unpaid claim. You have 2 years from our first denial notice to request Formal Appeal. To help us make a decision on your appeal, you or your provider should also send us any more information (that you haven’t already sent us) to show why we should authorize the requested service or pay the claim. Send your appeal request and information to:
Name: Title: Address:
Barbara Chipres Compliance Manager 5171 Verdugo Way Camarillo, CA 93012
Phone: (877) 527-6173
Our acknowledgement: We have 5 business days after we receive your request for Formal Appeal (“the receipt date”) to send you and your treating provider a notice that we got your request.
Our decision: For denied claims, we have 60 days to decide whether we should change our decision and pay your claim. We will send you and your treating provider our decision in writing. The written decision must explain the reasons for our decision and tell you the documents on which we based our decision.
If we deny your request or claim: You have 30 days to appeal to Level 3.
If we grant your request: We will pay the claim and the appeal is over.
If we refer your case to Level 3: We may decide to skip Level 2 and send your case straight to an independent reviewer at Level 3.