Benefits Appeal Process
If you believe that you have been inappropriately denied payment of a claim as described in the Summary Plan Document or the Managed Care Plan Supplements, you are encouraged to call the plan’s administrator number for an explanation. If you are unsatisfied with the response, send a written Level 1 Review request as described below. If you are not satisfied with the response to the Level 1 Review, you may request a formal Level 2 Review. A Level 1 Review must be conducted prior to a request for a Level 2 Review. Typically most issues can be solved through the less formal Level 1 Review process.
Level 1 Review
MEDICAL AND DENTAL CLAIMS
When a claim for medical or dental benefits is processed, you will receive an Explanation of Benefits (EOB) from the company that processed the claim. This provides an explanation of any denials or reduction in benefits. You may request further explanation of the reasons by calling the number on the EOB or the customer service number on your identification card for the plan. If not satisfied with the explanation, you may send a written request for a Level 1 Review within 90 days of receipt of the EOB to your plan administrator.
PRESCRIPTION DRUG CLAIMS
If you believe that you have been inappropriately denied prescription drug benefits described in the Summary Plan Document, you are encouraged to call the customer service number on your prescription drug identification card for an explanation. If you are unsatisfied with the response, you may submit a written informal, or Level 1, appeal to MedImpact within 60 days of the denial or benefit reduction you are appealing.
LIFE INSURANCE, ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D), AND LONG TERM CARE INSURANCE CLAIMS
If you receive a notice that a life or AD&D insurance claim has been denied, you may call the Standard Insurance company for an explanation. If you are not satisfied, you may send a written request for a review along with supporting documentation to The Standard Insurance Company within 60 days of receipt of the denial. If you receive a notice that a long term care insurance claim has been denied, you may call Unum Life Insurance company for an explanation. If you are not satisfied with the explanation, you may send a written request for a review along with supporting documentation to Unum Life Insurance Company within 60 days of receipt of the denial.
VISION INSURANCE CLAIMS
If you are denied vision insurance benefits, you or your vision provider may call Eyemed for an explanation. If you are unsatisfied with the response, you may send a written request for a review to Eyemed within 60 days.
Level 2 Review
MEDICAL AND DENTAL CLAIMS
If you are not satisfied with the response to a Level 1 Review, you may initiate a formal petition for Level 2 Review by Health Care and Benefits Division (HCBD). A petition for review must be in writing, stating the reason or reasons you or your health care provider are disputing the denial, and include documentation of the informal review process. This petition must be filed with HCBD within 90 days of the date of the notice of the informal review denial. HCBD will review the arguments presented and may forward the petition to the claims administrator who denied the claim for a formal reconsideration, if circumstances warrant. A written decision will be made by HCBD within 30 days of the date the petition is filed or within 120 days if special circumstances require an extension.
PRESCRIPTION DRUG CLAIMS
If you are not satisfied with the response to the Level 1 Review of a prescription drug claim, you may submit a second appeal to MedImpact within 60 days of receipt of the response. The claim will be reviewed by a special review committee of representatives of MedImpact. A written response will be issued within 30 days, or within 60 days if special circumstances require an extension.
VISION INSURANCE, LIFE INSURANCE, ACCIDENTAL DEATH AND DISMEMBERMENT, AND LONG TERM CARE INSURANCE CLAIMS
Since vision, life, accidental death and dismemberment, and long term care insurance plans are not self-insured by your employer, final claims decision are made by the relevant insurance company. You may request information from HCBD about the policy and contract terms by submitting a copy of the denial and other documentation to HCBD within 60 days of receipt of the decision.
Member Responsibility
Failure to file a petition for Level 1 review within Level 1 time frames or to file a petition for a Level 2 review within Level 2 time frames shall constitute a waiver of the right to file or continue a Level 2 petition.
Appeal of Prior Authorization and Certification Actions
If you or your physician disagrees with a certification denial of inpatient services under an indemnity medical plan or a prior authorization decision, you have 60 days to submit an appeal request. You can do this by calling the customer service number on your identification card. The claims administrator will send you the necessary forms to initiate the process. The decision on the review will be made in writing within 60 days after receipt of all relevant medical records.
If you are on a managed care plan and are informed that requested services will be denied as not medically necessary or not a benefit of the plan, you may initiate a Level 1 and Level 2 review as described above.
