Whom to contact:

Your insurance carrier

Who can appeal:

You or your authorized representative

What you can appeal:

Adverse benefit determinations of medical necessity.

When you can appeal:

You may appeal within 180 calendar days from the date of the final review decision of the internal review process.

What to send:

Independent reviews need to be requested in writing, while expedited reviews may be submitted orally or in writing. You will want to provide the insurer with as much information as possible so the independent review organization can conduct a complete and fair review.

What you must pay:

No charge

What will happen:

Your request for a review will be handled as an independent review, unless there is an urgent medical situation and then it will be handled as an expedited review.

Independent reviews:

1. You must exhaust the insurers internal review process unless you and the insurer mutually agree to waive the internal process.
2. You must send your insurer a written request for an independent review within 180 days from the date of the final internal review decision.
3. Your insurer will select an Independent Review Organization to conduct the review.
4. Your insurer will send you notification of the Independent Review Organization’s decision. This notification will include the reasons for the decision, reference to the specific plan provision on which the decision is based.
5. The independent review decision can be binding and final.

Expedited reviews:

1. You may submit a request for an expedited review either orally or in writing. If your insurer receives an oral request for an expedited review, the insurer will send you a written confirmation of the request within 24 hours.
2. Your insurer will select an Independent Review Organization to conduct the review.
3. Your insurer will send you notification of the Independent Review Organization’s decision. This notification will include the reasons for the decision, reference to the specific plan provision on which the decision is based.
4. The expedited review decision is binding and final.

When you will get a decision:

Within 30 days for an Independent Review of a pre-service claim, and within 60 days for a post-service claim.

In urgent situations:

The insurer will notify you as soon as possible, but no later than 72 hours after receiving your request for an expedited review.