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¾ Insured has specific rights and responsibilities (including rights to information, attend the appeal committee meeting, submit new information, to be represented in person) ¾ Review is being managed by a designated individual and any questions should be directed to this individual (the name and telephone number of the individual is provided to the requester in acknowledgment letter)

UNICARE, in communicating in writing a specific decision to the insured, may include the following information as is necessary or required by applicable state or federal regulation:

  • Statement of the reviewer’s understanding of the reasons for the appeal

  • Qualifications of the responsible professional, including licensure of panel members

  • Reviewer’s decision, i.e., recommendation of review panel

  • UNICARE’s decision and rationale if different from panel’s recommendation

  • Reference to the Plan provision supporting the decision

  • Reference to any other evidence or documentation supporting the decision

  • Statement indicating the insured’s right to appeal the decision to the Plan Administrator or appropriate state regulator, including the telephone number and address of the commissioner

  • Statement concerning right of insured under ERISA Section 502(a) with respect to civil action

  • Statement indicating the decision is UNICARE’s final determination

UNICARE will contact the insured either by telephone or in writing if additional information is required in order to process the appeal. Such contact will include providing the insured with the necessary form(s) and/or instructions for obtaining the additional information (e.g. an authorization for release of information).

If the insured does not fulfill their responsibilities related to the investigation (e.g., has not provided sufficient requested information, a signed authorization for release of information, etc.) during the sixty (60) day investigation, UNICARE will inform the insured that the requested information has to be provided or the appeal will be closed.

UNICARE will close the appeal file if requested information is not received within ten (10) working days after the sixty 60-day period and will notify the insured of closure due to failure to respond.

All information related to the appeal will be internally reviewed by a committee consisting of individuals who were not involved in the decision being appealed.

All information pertaining to the appeal will be filed and maintained for a period of seven (7) years.

48657MN

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