Housecall Newsletter - ConnectiCare

ight to appeal
IF YOU’RE NOT SATISFIED
You have the right to appeal a decision if we do not provide coverage for a treatment or service.
There may be times when you do not agree with a
decision that we make about “Medical Necessity.”
This is important because if a service is not considered
Medically Necessary, we will not pre-authorize it or
provide coverage for it. As a result, your plan will not
pay for the service at the highest level of benefits, or
your plan may not pay for the service at all.
If you do not agree with our decision, you have the
right to request an appeal.
YOUR MEDICAL-NECESSITY APPEAL WILL
RECEIVE INDEPENDENT REVIEW
We will forward your appeal to an independent review
organization. A board-certified physician will review
the case. The physician will be a specialist in the field
related to the condition in the appeal. He or she will not
have been involved in the original decision, and will not
be a ConnectiCare employee.
If you’re not satisfied with the review decision, there
is another step. You may be eligible for an external
review. This is provided through the state in which your
insurance plan was issued or through an independent
review organization for self-funded plans. When we
send you the review decision, we’ll provide information
in writing about how to pursue an external review.
WHAT IS THE DEFINITION OF
‘MEDICALLY NECESSARY’
“Medically Necessary” means health services that a
health care practitioner, exercising prudent clinical
judgment, would provide to a patient for the purpose of
preventing, evaluating, diagnosing or treating an illness,
injury, disease or its symptoms, and that are:
• In accordance with generally accepted standards
of medical practice
• Clinically appropriate, in terms of type, frequency,
extent, site and duration considered effective for
the patient’s illness, injury or disease, and
• Not primarily for the convenience of the patient,
physician or other health care provider; and not
more costly than an alternative service or sequence
of services at least as likely to produce equivalent
therapeutic or diagnostic results as to the diagnosis
or treatment of that patient’s illness, injury or disease.
We use medical protocols
developed from national
standards with input from
local physicians, including
specialists, to establish
our guidelines for
what is considered
Medically Necessary.
PEACE OF MIND FOR EVERY WOMAN
Your coverage under Women’s Health and Cancer Rights Act
Do you know that your plan provides benefits for mastectomy-related services, as required by the Women’s
Health and Cancer Rights Act of 1998 Covered benefits include all stages of reconstruction and surgery to
achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including
lymphedema. These services offer peace of mind for any woman with breast cancer who chooses to have a
mastectomy. For more information, contact your benefits administrator or go to the U.S. Department of Labor
website at www.dol.gov and enter “WHCRA” in the search field.