Urgent Internal Review
If your request for benefits meets the definition of a preservice claim (meaning, you must obtain preapproval prior to receiving the service), and we deny your request for benefits, you may be eligible for an urgent expedited internal review if a physician substantiates either orally or in writing that adhering to the timeframe for the internal review process would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function.
You or your authorized representative may file a request for an urgent internal appeal only when you think that we have wrongfully denied, terminated or reduced coverage for a health care service prior to your having received that health care service, or if you believe we have failed to respond in a timely manner to a request for benefits or payment.
The procedure is as follows:
You may submit your urgent internal appeal request by telephone. The required physician's substantiation that your condition qualifies for an expedited grievance can also be submitted by telephone.
To initiate an urgent appeal, you may call the number included in the notice denying approval for the services.
We will provide you with our decision within 72 hours of receiving both your urgent request and the physician's substantiation.
If you do not agree with our decision, you may, within 10 days of receiving it, request an urgent external review.
You should also know
- You may authorize another person (including your physician), to act on your behalf at any stage in the expedited internal grievance process. Your authorization needs to be in writing.