PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

If the appeal denial is based on medical necessity,
experimental, or a similar exclusion or limit,
the notice will provide either an explanation
of the scientific or clinical judgment for the
determination (applying the terms of this Plan
to the participant’s medical circumstances) or a
statement that such explanation will be provided
free of charge upon request.
Second Appeal of a Claim Denial
A claimant may appeal a denial on appeal of
a pre-service claim or post-service claim, but
the claimant must do so within 90 days (or any
longer period that may be specified by the PPO/
DRP administrator) after receiving written notice
of the denial (or partial denial) of the appeal. All
of the procedures for a first level of appeal of a
claim denial apply for the second level appeal of a
claim denial, except that the second level appeal
will be decided and notice of the decision will be
provided as follows:
Pre-Service
Claims
Post-Service
Claims
Within a reasonable period, but not
later than 15 days after the claimant
filed the second level appeal request.
Within a reasonable period, but not
later than 30 days after the claimant
filed the second level appeal request.
External Review Process
Beginning January 1, 2011, a claimant may request
an external review of certain types of denials within
4 months after the receipt of the denial notice.
A claimant may request an external review of a
rescission of coverage under the Plan, or of a denial
that involved “medical judgment.” Examples of
“medical judgment” include determinations based
on medical necessity, appropriateness, health care
setting, level of care, or effectiveness of a covered
benefit and determinations that a treatment is
experimental or investigational. This external
review process is not available for a claim or
appeal denial related to the claimant’s failure to
meet the requirements for eligibility under the
terms of the Plan and is not available until the
claimant has exhausted (unless the claimant is
not required to exhaust) the applicable internal
claims and appeals process under the Plan.
To request an external review of a denial by Blue
Cross and Blue Shield of Illinois, contact:
Claim Review Section
Health Care Service Corporation
P.O. Box 2401
Chicago, Illinois 60690
To request an external review of a denial by
Humana, contact:
Humana Grievance and Appeals
P.O. Box 14546
Lexington, KY 40512-4546
Within 5 business days of receiving the
claimant’s external review request, the PPO/
DRP administrator will complete a preliminary
review of this request and will provide the
claimant with written notice within 1 business
day after completing its preliminary review.
The preliminary review determines whether (i)
the claimant is or was covered under the Plan
at the time the health care item or service was
requested or provided, (ii) the denial relates to
the claimant’s failure to meet the requirements
for eligibility under the Plan, (iii) the claimant
has exhausted (or is not required to exhaust)
the Plan’s internal appeal process, and (iv) the
claimant has provided all of the information and
forms required to process an external review.
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