In the event of an adverse determination, what type of notification is sent to the member when BCBSM or BCN is handling all levels of appeal?
If there is an adverse determination, health plans must follow these guidelines:
- Written or electronic notice of adverse determinations, including explanation of benefits, must state the reason for denial with as much specificity as possible. The notice must contain a description of the plan's review procedures and the time limits applicable to such procedures, including a statement of the member's right to bring a civil action following an adverse benefit determination.
- When notice of an adverse benefit determination is given, the member must be notified of his or her right to receive upon request and free of charge: internal rules, guidelines, protocols, or other similar criteria relied upon in making the determination. In cases involving medical necessity or experimental treatment, health plans must provide free of charge and explanation of the scientific or clinical judgment for the determination, if requested.