You have the right to appeal, or request an independent review of, any action we take or decision we make about your coverage, benefits or services. You can appeal through either a written or verbal request. There are several levels of appeal, including internal and external appeal levels, which you may follow. Contact us as soon as possible because time limits apply.
What is an appeal?
When we make a decision about what services we will cover or how we'll pay for them, we let you know. Usually we will send you an explanation of benefits statement or a letter denying a pre-authorization request. An appeal is a request from a member, or an authorized representative, to change a decision we have made about:
- Access to health care benefits, including a pre-authorization request denial
- Claims payment, handling or reimbursement for health care services
- Other matters as required by state or federal law
Who is a member?
A member is:
- A person who has bought insurance for themselves (also called a contract holder) and any dependents they choose to enroll
- Someone who has insurance through an employer, and any dependents they choose to enroll
Who can appeal?
The member can appeal, or a representative the member chooses, including an attorney or, in some cases, a doctor.
How to appeal
You can appeal a decision in writing or verbally. You must appeal within 180 days of getting our written decision. Be sure to include any other information you want considered in the appeal.
Appropriate staff members who were not involved in the earlier decision will review the appeal. Once that review is done, you will receive a letter explaining the result.
To appeal in writing
Use the appeal form in the sidebar. Instructions are included on how to complete and submit the form. You can also get information and assistance on how to submit a written appeal by calling the Customer Service number on the back of your member ID card.
To appeal verbally
Call the phone number on the back of your member ID card. Customer Service will help you with the process.
For member appeals that qualify for a faster decision, there is an expedited appeal process.
An independent, external review may also be available.
When you ask, we will supply copies of the relevant records we used to make our initial decision or appeal decision for free. Those documents will include the specific rules, guidelines or other similar criteria that affected the decision.
The member appeal process varies by type of plan in order to follow state and federal law. You can find more details about the member appeal process in your benefit booklet (also called a summary plan description). You can find your benefit booklet by signing in and going to your Benefits page.
If you have any questions about your member appeal process, call our Customer Service department at the number on the back of your member ID card.
People with a hearing or speech disability can contact us using TTY: 711.
Para asistencia en español, por favor llame al teléfono de Servicio al Cliente en la parte de atrás de su tarjeta de miembro.
Para humingi ng tulong sa Tagalog, pakitawagan ang numero ng telepono ng Serbisyo sa Kostumer (Customer Service) na nakasulat sa likod ng inyong kard bilang miyembro.
Diné kʼehjí áká'eʼyeedgo, t'áá shǫǫdí áká anídaalwoʼí bi béésh bee haneʼé ninaaltsoos bee atah nílínígíí bineʼdę̀ę̀ bikááʼ.