PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step 2: We consider your request and we give you our answer. Deadlines for a “fast” coverage decision • If we are using the fast deadlines, we must give you our answer within 24 hours. � Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to. 165 � If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization. Later in this section, we tell about this review organization and explain what happens at Appeal Level 2. • If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor’s statement supporting your request. • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. Deadlines for a “standard” coverage decision about a drug you have not yet received • If we are using the standard deadlines, we must give you our answer within 72 hours. � Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to. � If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this section, we tell about this review organization and explain what happens at Appeal Level 2. • If our answer is yes to part or all of what you requested – � If we approve your request for coverage, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor’s statement supporting your request. • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.
166 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Deadlines for a “standard” coverage decision about payment for a drug you have already bought • We must give you our answer within 14 calendar days after we receive your request. � If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this section, we tell about this review organization and explain what happens at Appeal Level 2. • If our answer is yes to part or all of what you requested, we are also required to make payment to you within 14 calendar days after we receive your request. • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. Step 3: If we say no to your coverage request, you decide if you want to make an appeal. • If we say no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made. Section 6.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a coverage decision made by our plan) Legal Terms An appeal to the plan about a Part D drug coverage decision is called a plan “redetermination.” Step 1: You contact us and make your Level 1 Appeal. If your health requires a quick response, you must ask for a “fast appeal.” What to do • To start your appeal, you (or your representative or your doctor or other prescriber) must contact us. � For details on how to reach us by phone, fax, or mail for any purpose related to your appeal, go to Chapter 2, Section 1, and look for the section called, How to contact our plan when you are making an appeal about your Part D prescription drugs. • If you are asking for a standard appeal, make your appeal by submitting a written request. You may also ask for an appeal by calling us at the phone number shown in Chapter 2, Section 1 (How to contact our plan when you are making an appeal about your Part D prescription drugs). • If you are asking for a fast appeal, you may make your appeal in writing or you may call us at the phone number shown in Chapter 2, Section 1 (How to contact our plan when you are making an appeal about your part D prescription drugs).
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PPO II - EmblemHealth

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