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Monday, September 27, 2010

Denial appeal time limit - Prestige health insruance

3. Request for Standard Determination
In the event a provider wishes to file an appeal on behalf of a member, the provider and member must complete an Appointment of Representative statement, which can be found in the Forms section of the Provider Manual, to request a standard determination. Prestige Health Choice will make a determination and provide written notice of the resolution of the Appeal within 45 calendar days from the date of receipt of the standard request.

4. Request for Retrospective Determination

The provider and member must complete an Appointment of Representative statement, which can be found in the Forms section of the Provider Manual, to file a request for a retrospective determination.

Prestige Health Choice will make a determination and provide written notification within 45 calendar days from the date of receipt of the retrospective request.

5. 14-Day Extension

The Expedited, Standard and Retrospective Determination periods may be extended by up to 14 calendar days, if the member requests an extension or if Prestige Health Choice justifies a need for additional information and documents how the extension is in the interest of the member. If an extension had not been requested by the member, Prestige Health Choice will provide the member with written notice of the reason for the delay.

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