State of Illinois - HealthLink

appropriateness, health care setting, and level of care or effectiveness and denials for services
determined by the claim administrator to be experimental or investigational.
Administrative appeals pertain to claim denials based on plan design and/or contractual
interpretations of plan terms that do not involve any use of medical judgment.
Except for expedited external reviews, the internal appeal process must be followed through
before the member may seek external review or other available appeal levels.
A. First Level/Internal Appeals – First level appeals must be initiated with the claim
administrator within 180 days of the date of receipt of the initial adverse benefit
determinations. An expedited review may be requested orally or in writing if you, your
contracted HealthLink provider or other health care provider involved in the appeal
believes that the denial of coverage of health care services could significantly increase risk
to your health. Non-urgent appeals should be submitted to:
HealthLink Grievances and Appeals
PO Box 411424
St. Louis, MO 63141-1424
All appeals will be reviewed and decided by an individual(s) who was not involved in the
initial claim decision. Each case will be reviewed and considered on its own merits. If the
appeal involves a medical judgment, it will be reviewed and considered by a qualified
health care professional. In some cases, additional information, such as tests results, may be
required to determine if additional benefits are available. Once all required information has
been received, the claim administrator shall provide a decision within the applicable time
frame: 15 days for pre-service claims; 30 days for post-service claims; or 72 hours for
urgent care claims.
B. Final Benefit Determination – Administrative Appeals Only – After exhausting the first
level/internal appeal available, if the member still feels that the claims administrator benefit
determination is not consistent with the published benefit coverage through the claim
administrator, they may appeal the claim administrator’s decision to CMS Group Insurance
Division. For an appeal to be considered by CMS Group Insurance Division, the member
must appeal in writing within 60 days of the date of receipt of the claim administrator’s
final internal adverse benefit determination. All appeals must be accompanied by
documentation to support the request for reconsideration. Submit administrative appeal
documentation to:
CMS Group Insurance Division
801 S 7 th Street
PO Box 19208
Springfield, IL 62794-9208
The decision of CMS Group Insurance Division shall be final and binding on all parties.
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