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Sunday, June 6, 2010

Request for Standard Pre-Service Determination

If the provider is filing a standard pre-service appeal on a member’s behalf, the provider and member must
complete an Appointment of Representative statement, which can be found in the Forms section of this manual.
The Plan will make a determination and provide notification within 30 calendar days of receipt of the
standard pre-service request.

The provider can request a medication appeal without the necessity of an AOR form to be submitted.

Affirmation of Denial
If the Plan upholds its initial action and/or denial (in whole or in part), it will:

* Submit a written explanation for a final determination with the complete case file to theindependent review entity (IRE) contracted by CMS.
o The IRE must issue a final determination as expeditiously as the member’s health or
condition requires, but no more than 30 calendar days from receipt of the case.
o If the IRE agrees with the Plan, the IRE will notify the member and the Plan and give
the member further appeal rights.

*  Notify the member of the decision to affirm the denial and that the case has been forwarded to
the IRE

If the Plan upholds its initial action and/or denial (in whole or in part) for a medication, it will:

- Notify the member of the decision to uphold the original medication denial orally and in writing.
- Provide the member the appeal rights to submit the next level of appeal to the IRE if they do not
agree with the redetermination decision.


Reversal of Denial

If the Plan overturns its initial action and/or denial, it will notify the member verbally and in writing within
30 calendar days of receipt of the determination request

If the IRE overturns the denial, the IRE notifies the member or representative in writing of the decision.

*  The Plan will also notify the member, member’s representative and provider verbally and in writing
that the services are approved and provide an authorization number within 72 hours, if the
member’s condition warrants it, or no more than 14 calendar days from receipt of the IRE’s
determination.

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