CALIFORNIA - Pacificare Health Systems

PART A
122
Overseeing Your Health Care
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30 days for a non-urgent pre-service request
(the denial of an initial request for a service not
yet provided)
60 days for a post-service claim (the denial of a
claim for services already provided but not yet
paid for)
4. The Member agrees that their Provider will be
their “authorized representative” (pursuant to
ERISA) regarding the receipt of approvals of
requests for Covered Services for purposes of
medical management.
5. ERISA provides for a maximum of two (2)
mandatory appeal levels. Members enrolled in
employee welfare benefit plans subject to ERISA
may have the right to bring civil action under
Section 502(a) of ERISA if all required reviews of
their claim have been completed and the claim
has not been approved.
6. A Member’s participation in a voluntary appeal
level does not effect their legal rights provided
under ERISA. Any statute of limitations applicable
to pursing civil action will be tolled during the
period of a voluntary level of appeal.
7. Binding Arbitration of claims, as described in this
section of this Combined Evidence of Coverage
and Disclosure Form, will be limited to claims
that are not subject to ERISA.