Level 3: External, Independent Review
Your request: You may appeal to Level 3 only after you have appealed through Level 2. You have 30 days after you receive our Level 2 decision to send us your written request for External Independent Review. Send your request and any more supporting information to:
Name: Title: Address:
Barbara Chipres Compliance Manager 5171 Verdugo Way Camarillo, CA 93012
Phone: (877) 527-6173
Neither you nor your treating provider is responsible for the cost of any external independent review.
The process: There are two types of Level 3 appeals, depending on the issues in your case: (1) Medical necessity These are cases where we have decided not to pay a claim because we think the services that were provided were not medically necessary to treat your problem. For medical necessity cases, the independent reviewer is a provider retained by an outside independent review organization (IRO), procured by the Arizona Insurance Department, and not connected with our company. For medical necessity cases, the provider must be a provider who typically manages the condition under review.
(2) Contract coverage These are cases where we have denied coverage because we believe the requested service is not covered under your insurance policy. For contract coverage cases, the Arizona Insurance Department is the independent reviewer.
Medical Necessity Cases
Within 5 business days of receiving your request, we must:
Mail a written acknowledgement of the request to the Director of Insurance, you, and your treating provider.
Send the Director of Insurance: the request for review; your policy, evidence of coverage or similar document; all medical records and supporting documentation used to render our decision; a summary of the applicable issues including a statement of our decision; the criteria used and clinical reasons for our decision; and the relevant portions of our utilization review guidelines. We must also include the name and credentials of the health care provider who reviewed and upheld the denial at the earlier appeal levels.
Within 5 days of receiving our information, the Insurance Director must send all submitted information to an external independent review organization (the “IRO”).
Within 21 days of receiving the information the IRO must make a decision and send the decision to the Insurance Director.
Within 5 business day of receiving the IRO’s decision, the Insurance Director must mail a notice of the decision to us, you, and your treating provider.
The decision (medical necessity): If the IRO decides that we should provide the service or pay the claim, we must authorize the service or pay the claim. If the IRO agrees with our decision to deny the service or payment, the appeal is over. Your only further option is to pursue your claim in Superior Court.