Utilization Management Appeal Process and Timeframes for ...

• A statement disclosing the Member's right to contact the InsuranceCommissioner or the Health Care Advocate at any time and their contactinformation.• A statement describing the procedures for obtaining an external reviewof the final adverse determination.When applicable, the written appeal decision notice will include the followingstatement: "You and your plan may have other voluntary alternative disputeresolution options such as mediation. One way to find out what may be availableis to contact your state Insurance Commissioner."The notice will also include a statement disclosing the Member's right to contactthe commissioner's office or the Office of the Healthcare Advocate at any time.These statements will include the current contact information for both offices.After all internal levels of appeals have been exhausted (First Level and SecondLevel), the Member has the right to file a civil action under 502(a) of theEmployee Retirement Income Security Act (ERISA). ERISA rights apply to allConnecticut plans except individuals, church groups and municipalities.2. Member External Appeal LevelNote: For expedited external appeals, please refer to policy: Expedited Appeal Process.Clinical review conducted by an external agent of the appropriate state. Information onhow to submit an external appeal is outlined in the initial denial letter and all subsequentappeal decision letters. All Connecticut commercial plan Members (except self-funded*)are entitled to this level, after he or she has completed the first level, internal grievanceprocess. However, the enrollee may be able to request the external review prior toexhausting the internal appeals process if the health carrier agrees to waive the internalappeals process.* Employees of the State of Connecticut may file an external appeal through the State ofConnecticut Insurance Department. All other self-funded groups do not have externalappeal rights.Submission timeframe: The submission of an external appeal to the State ofConnecticut Insurance Commissioner must be done within 120 calendar days from thedate of receipt of the adverse determination or Grievance Review Board Decision. ForRhode Island residents who are Members of Connecticut plans and choose to utilize theState of Rhode Island external appeal process, submission of an external appeal toOxford must be done within 120 calendar days from the date of receipt of the GrievanceReview Board Decision.Preliminary Review: Within five business days after receiving a copy of a standardexternal review request for the State of Connecticut Insurance Commissioner, onecalendar day after receiving a copy of an expedited external review request, Oxford mustcomplete a preliminary review to determine whether:1. The enrollee was a covered person under the health benefit plan at the time thehealth care service was requested or provided;2. The involved health care service is a covered service under the covered person'shealth benefit plan except for the health carrier's determination that it does notmeet its requirements for medical necessity, appropriateness, health care setting,level of care, or effectiveness;Utilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)9©1996-2013, Oxford Health Plans, LLC