#6 Appeal Self Insured/Non-Grandfathered – Subject to Health Care Reform PA – HMO, PPO, POS, Trad IBC is claim fiduciary – IBC does the entire appeal process Group is claim fiduciary - IBC does the entire appeal process; Group has the final determination (08/2016) IMPORTANT INFORMATION IF YOU CHOOSE TO APPEAL
We want to help you understand your benefits and the reasons for this determination. Please contact a Member Services Representative at the number on the back of your plan ID card to discuss your questions and concerns. If you are dissatisfied with this decision, you, or someone you name to act for you as your authorized representative (designee), including an attorney, have the right to appeal the denial. You or your designee must file the appeal within at least 180 days of receipt of this notice. For information about naming a designee, call Member Services at the telephone number listed on the back of your health plan identification card. Full and Fair Review. You or your authorized representative is entitled to a full and fair review. Specifically, at all levels of internal appeal, you or your authorized representative may submit additional information pertaining to the case to the Plan. You or your authorized representative may specify the remedy or corrective action being sought. At your request, the Plan will provide access to, and copies of all relevant documents, records, and other information that are not confidential, proprietary, or privileged. The Plan will automatically provide you or your authorized representative with any new or additional evidence or new rationale considered, relied upon, or generated by the Plan in connection with the appeal. Such evidence or new rationale is provided as soon as possible and in advance of the date the final internal adverse benefit notification is issued. This information is provided to you or your authorized representative free of charge. For medical necessity issues, should you desire more information about the decision and/or a free copy of the internal guidelines or protocol used to make the decision, please send a written request including the Reference Number found at the top of this letter to “Clinical Rationale” at the address provided below. To file an appeal of this determination, call, write, or fax a request to: Independence Blue Cross The Member Appeals Department P.O. Box 41820 Philadelphia, PA 19101-1820 Phone: 1-888-671-5276 Fax: 1-888-671-5274 If you decide to appeal, the following summary gives you general information about the appeal process. THE TWO TYPES OF APPEAL
Medical Necessity/Grievance. An appeal of an adverse decision based upon medical necessity or, decisions that were made based upon identification of treatment as cosmetic or experimental/investigative. Administrative/Complaint. An appeal regarding an unresolved dispute including contract exclusions/limitations, participating or non-participating healthcare provider status, non-covered services, cost sharing requirements, and rescission of coverage (except for failure to pay premiums or coverage contributions).
At each level of appeal, you or your designee may, at any time, request the aid of a Plan employee in preparing or presenting your appeal at no charge. This employee has not participated in the previous decision to deny coverage for the issues in dispute and is not a subordinate of anyone who previously reviewed the file. If you would like assistance in preparing your appeal, please call the number listed above. INTERNAL APPEALS – STANDARD AND EXPEDITED
Standard Appeals Pre-service Appeal. An appeal for benefits that, under the terms of this Contract, must be pre-certified or preapproved before medical care is obtained in order for coverage to be available. - HMO, PPO, POS only: You have two (2) levels of Standard Pre-service Internal Appeal that are completed within 15 calendar days of receipt of request for each level of Internal Appeal. - Traditional plans only: You have one (1) level of Standard Pre-service Internal Appeal that is completed within 30 calendar days of receipt of request. Post-service Appeal. Post-service is concerning claims that have been received for services that the Covered Person has already obtained. - HMO, PPO, POS only: You have two (2) levels of standard post-service internal appeal that are completed within 30 calendar days of receipt of request for each level of internal appeal. - Traditional plans only: You have one (1) level of Standard Post-service Internal Appeal that is completed within 60 calendar days of receipt of request. Urgent Care/Expedited Appeals. An Urgent Expedited Appeal is any appeal for medical care or treatment with respect to which the application of the time periods for making non-urgent determinations could seriously jeopardize the life or health of the Covered Person or the ability of the Covered Person to regain maximum function, or in the opinion of a physician with knowledge of the Covered Person’s medical condition, would subject the Covered Person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the appeal. –
Your appeal review is completed within 72 hours of the appeal request.
Note: If you believe your situation is urgent, you may request an Expedited External Review. You have the right to file an Expedited External Review at the same time as the Internal Expedited Appeal for urgent and ongoing care. To file an appeal, call, write, or fax a request to the address above. INFORMATION ABOUT EXTERNAL REVIEW
You have only one (1) level of Standard or Expedited External Review by an Independent Review Organization (IRO). An External Review process is available for any adverse benefit determination that involves medical judgment as determined by the external reviewer and for rescissions of coverage. You, or your designee, are not required to pay any costs associated with the External Review. The IRO has no direct or indirect professional, familial, or financial conflicts of interest with Independence Blue Cross (IBC). The Plan’s arrangement and payment of the IRO does not constitute a conflict of interest. Standard External Review. You, or your designee, may request a Standard External Review by calling or writing the Plan to the address above within 180 days of receiving the Internal Appeal decision letter. The IRO makes the final decision within 45 calendar days of receiving request. The IRO notifies you, your designee, and IBC for Standard External Review. Expedited External Review. You have 72 hours from receipt of determination letter to submit an Expedited External Review request by calling the Plan at the number above. Expedited External Review is completed within 72 hours of the request.
The decision of the External Review is binding on the Plan. If you are not satisfied with the External Review decision, you may wish to consult with the Group Plan Administrator for your health plan. If your health plan is subject to the requirements of the Employee Retirement Income Security Act (ERISA), following your appeal you may have the right to bring civil action under Section 502(a) of the Act. For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan fails to “strictly adhere” to the internal appeals process, you may initiate an external review or file appropriate legal action under state law or ERISA unless: Violation was de minimis (minimal). Did not cause (or likely to cause) prejudice or harm to the claimant. Was for good cause or due to matters beyond the control of the insurer/plan. In the context of a good faith exchange of information with the claimant. Not part of a pattern or practice of violations.
To learn more about your appeal process, refer to your Member Handbook or Evidence of Coverage or call Member Services at the telephone number listed on the back of your health plan identification card.
Language Assistance Services Spanish: ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted. Llame al número telefónico de Servicio al Cliente que figura en el reverso de su tarjeta de identificación. Chinese: 注意：如果您讲中文，您可以得到免费的语言 协助服务。请致电您ID卡背面的客户服务电话号码. Korean: 안내사항: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 ID 카드 뒷면에 있는 고객 서비스 번호로 전화해 주십시오. Portuguese: ATENÇÃO: se você fala português, encontram-se disponíveis serviços gratuitos de assistência ao idioma. Ligue para telefone do Atendimento ao Cliente que está no verso do seu cartão de identificação. Gujarati:
ૂચના: જો તમે
ુ રાતી બોલતા હો, તો િન: ુ ક જ
ભાષા સહાય સેવાઓ તમારા માટ ઉપલ ધ છે . પ ૃ યા તમારા આઇડ કાડની પાછળ
ાહક સેવા નંબર પર કોલ કરો.
Vietnamese: LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho bạn. Hãy gọi số Dịch Vụ Chăm Sóc Khách Hàng ở mặt sau thẻ ID của bạn. Russian: ВНИМАНИЕ: Если вы говорите по-русски, то можете бесплатно воспользоваться услугами перевода. Позвоните в службу поддержки клиентов по номеру телефона, указанном на обратной стороне вашей идентификационной карты. Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer Obsługi klienta znajdujący się na odwrocie Twojego identyfikatora. Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiami il numero dell’Assistenza clienti che troverà sul retro della sua tessera identificativa.
Arabic:
فإن خدمات المساعدة اللغوية، إذا كنت تتحدث اللغة العربية:ملحوظة الرجاء االتصال برقم "خدمة العمالء" الموجود.متاحة لك بالمجان .على ظھر بطاقة ھويتك French Creole: ATANSYON : Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Tanpri rele nimewo Sèvis Kliyantèl ki sou do kat idantifikasyon ou a. Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Mangyaring tawagan ang numero ng Customer Service na nasa likod ng iyong ID card. French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Veuillez composer le numéro du service clientèle indiqué au dos de votre carte d'identité Médicale. Pennsylvania Dutch: BASS UFF: Wann du Pennsylvania Deitsch schwetzscht, kannscht du Hilf griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Number uff die hinnerscht Seit vun dei ID Card uff fer schwetze mit ebber as dich helfe kann. Hindi: यान द: यिद आप िहंदी बोलते ह तो आपके िलए मु त म भाषा सहायता सेवाएं उपल ध ह। कृपया अपने
आईडी काडर् के पीछे िदए ग्राहक सेवा नंबर पर कॉल कर। German: ACHTUNG: Wenn Sie Deutsch sprechen, können Sie kostenlos sprachliche Unterstützung anfordern. Bitte rufen Sie unsere Kundendienstnummer auf der Rückseite Ihrer Identifikationskarte an. Japanese: 備考：母国語が日本語の方は、言語アシス タンスサービス（無料）をご利用いただけます。 ご自分のIDカードの裏面に記載されている カスタマーサービスの番号へお電話ください。 Persian (Farsi):
خدمات ترجمه به صورت، اگر فارسی صحبت می کنيد:توجه لطفا ً با شماره خدمات مشتريان.رايگان برای شما فراھم می باشد .که در پشت کارت شناسايی شما درج شده است تماس بگيريد
Y0041_HM_17_47643 Accepted 10/14/2016
Taglines as of 10/14/2016
Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh. T’11 sh--d7 h0d77lnih koj8’!k1’an7daalwo’j8 47 binumber naaltsoos nit[‘izgo nantin7g77 bine’d66’ bik11’. Urdu:
Mon-Khmer, Cambodian: សូមេម ្ត ចប់ ្របសិនេបើអនកនិយយភ ជំនួយែផនកភ
មន-ែខមរ ឬភ
នឹងមនផ្តល់ជូនដល់េ
រមមណ៍៖ ែខមរ េនះ
កអនកេ
យឥត
គិតៃថ្ល។ សូមទូរសពទេទេលខេស សមជិក ែដលមនេន ែផនកខងេ្រកយៃនបណ្ណ សមគល់ខួនរបស់ ្ល េ
កអនក ។
تو آپ کے لئے، اگر آپ اردو زبان بولتے ہيں:توجہ درکارہے مفت ميں زبان معاون خدمات دستياب ہيں۔ آپ کے شناختی کارڈ کے پيچھے دئيےگئے صارف خدمات نمبر پر برائے کرم کال .کريں
Discrimination is Against the Law This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This Plan provides: Free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats). Free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages.
Y0041_HM_17_47643 Accepted 10/14/2016
If you need these services, contact our Civil Rights Coordinator. If you believe that This Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator. You can file a grievance in the following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market Street, Philadelphia, PA, 19103; By phone: 1-888-377-3933 (TTY: 711), By fax: 215-761-0245, By email:
[email protected]. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Taglines as of 10/14/2016
