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Monday, September 27, 2010

Denial upheld and reversal of denial

6. Denial Upheld
If Prestige Health Choice upholds its initial action and/or  denial, then the member, member’s representative or provider will be notified in writing of the decision as well as any additional appeal rights that are available.

7. Reversal of Denial

If Prestige Health Choice overturns its initial action and/or denial, it will notify the member and provider verbally and in writing. Prestige Health Choice will authorize or provide the disputed services promptly, and as expeditiously as the member’s health condition requires, if the services were not furnished while the appeal was pending and the decision is to reverse a decision to deny, limit, or delay services. Prestige Health Choice also will pay for disputed services, in accordance with state policy and regulations, if the services were furnished while the appeal was pending and the disposition reverses a decision to deny, limit or delay services.

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