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Sunday, June 6, 2010

Examples of Appeals and Documentation Required

Medical Issues (or issues handled by the Medical Appeals and Grievances Dept.)
• Assistant surgeon
• Benefit plan limitations
• Claims that deny for no precertification
• Cosmetic procedures
• Contract Exclusions
• Ineligible provider
• Pre-existing conditions
• Waived conditions
• Investigational (member responsible)
• Not medically necessary (member responsible)

Documentation Required

• Detailed explanation of issue
• Must be accompanied by applicable medial records and/or operative report to support explanation
(Please note: Failure to submit supporting documentation may delay processing of your request.)

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