PPO II - EmblemHealth

2013 Evidence of Coverage for PPO II
Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
Chapter 9. What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
BACKGROUND
SECTION 1 Introduction ......................................................................................... 145
Section 1.1 What to do if you have a problem or concern ..........................................................145
Section 1.2 What about the legal terms? .....................................................................................145
SECTION 2 You can get help from government organizations
that are not connected with us ......................................................... 145
Section 2.1 Where to get more information and personalized assistance .....................................145
SECTION 3 To deal with your problem, which process should you use? .........147
Section 3.1 Should you use the process for coverage decisions and appeals?
Or should you use the process for making complaints? .........................................147
COVERAGE DECISIONS AND APPEALS
SECTION 4 A guide to the basics of coverage decisions and appeals ........... 148
Section 4.1 Asking for coverage decisions and making appeals: the big picture ...........................148
Section 4.2 How to get help when you are asking for a coverage decision or making an appeal ...148
Section 4.3 Which section of this chapter gives the details for your situation? ............................149
SECTION 5 Your medical care: How to ask for a coverage decision
or make an appeal .............................................................................. 150
Section 5.1 Th is section tells what to do if you have problems getting coverage for medical
care or if you want us to pay you back for our share of the cost of your care ..........150
Section 5.2 Step-by-step: How to ask for a coverage decision (how to ask our plan
to authorize or provide the medical care coverage you want) .................................151
Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a review
of a medical care coverage decision made by our plan) ..........................................154
Section 5.4 Step-by-step: How to make a Level 2 Appeal ............................................................157
Section 5.5 What if you are asking us to pay you for our share of a bill you
have received for medical care? ..............................................................................159
141