2013 USX Office SPD.pdf - US Xpress

4. Information as to how you may submit the claim for review and the applicable time limits.
5. A statement regarding your right to bring a civil suit under federal law should your appeal
be denied.
In the case of an urgent care claim, the notice of denial may be provided to you orally within the
72 hour period, so long as a written notice is provided within 3 days thereafter.
You may appeal a claim denial by following the appeal procedure explained below.
Appealing a Claim
If you do not agree with the denial or partial denial of your claim or if you have questions
concerning your claim, you are encouraged to contact the insurance carrier handling your claim.
If you wish to appeal a claim denial, you may need to complete a form provided and required by
your insurance carrier to file your appeal. In your appeal, you must state that you are requesting
an official review of your claim and the reason(s) why you do not agree with the denial or partial
denial of your claims and any additional information pertinent to the claim. You should contact the
insurance carrier to bring an appeal.
Except in the case of urgent care claims, the insurance carrier need not consider any telephone
inquiry as a request for an official review of a denied claim. However, if the claim which is denied
is an urgent care claim, you can request an expedited appeal by calling the insurance carrier
handling your claim.
If you want to appeal a denied claim, the insurance carrier must allow you at least 180 days after
you receive notice of a denial or partial denial to file the appeal. During the 180 days (or any
longer period the insurance carrier may allow), you or your representative may review and obtain
from the insurance carrier copies of all documents, records and information relating to your claim.
If you wish, you or your representative may submit written issues, comments and additional
justification as to why the claim should be allowed. The insurance carrier is required to provide
you with the name of each medical or vocational expert whose advice was obtained in connection
with your denied claim, regardless of whether the advice was relied upon.
When the insurance carrier reviews a denied claim, it may not afford any deference to the initial
decision. The review will be conducted by an individual, committee or department identified in
your subscriber contract or coverage certificate. If the benefit denial is based in whole or in part
on a medical judgment, such as whether the procedure is experimental or is not medically
necessary, the person reviewing the claim at the insurance carrier is required to consult with a
health care professional who has appropriate training and experience in the particular field of
medicine relating to your claim. This health care professional will be someone who was not
consulted on the initial claim denial.
The review of a claim denial is required to be done by the insurance carrier within the following
time frames:
Pre-Service Claim If the denied claim was a pre-service claim (other than an urgent care claim)
the insurance carrier is required to decide your appeal within 30 days.
Urgent Care Claim If the denied claim was an urgent care claim, the insurance carrier is
required to decide your appeal within 72 hours.
Post-Service Claim If the denied claim was a post-service claim, the insurance carrier is
required to decide your appeal within 60 days.
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