Appeals Basics
An appeal is a formal request to have Select Health reconsider what?
What is Benefits and/or claims payment decisions.
How many days does a member have to submit an appeal after notification of an adverse benefit determination?
180 days
Which level of appeal is available for all lines of business
Level 1
(fought urge to put, YOUR MOM)
If an appeal is approved as expedited, what is the maximum turnaround time?
72 hours.
Appeals can be submitted by fax, mail, email, online, or secure messaging
NO CAP!
Appeals must be submitted in what format?
What is in writing.
Name three ways a member can submit an appeal.
Online, fax, mail, email, or secure messaging.
Who reviews a Level 2 appeal?
The Select Health Grievance Committee.
Who determines whether an appeal qualifies for expedited review?
The Appeals Department.
Every appeal requested as expedited is automatically approved for expedited processing.
CAP
Who may file an appeal?
Who is The member, authorized representative, or provider.
How many days does a member have to request a Level 2 appeal after the Level 1 decision?
Within 60 days.
Should PBS caregivers enter approved appeal authorizations as overrides?
No! The PA team enters the authorization.
PBS caregivers should enter approved appeal authorizations as overrides if they don't appear in PAHub.
CAP!
What type of review does Select Health conduct for appeals?
What is a full and fair review?
Once an appeal is initiated, questions beyond status should be directed to whom?
The Appeals Department
Which type of plan is NOT eligible for a Level 2 appeal?
Individual plans.
If an approved appeal isn’t showing in PAHub, what should a caregiver do
Contact Appeals and ask them to fax the request to the PA team.
Individual plans are eligible for Level 2 appeals.
CAP
Who can request an external review?
Who is The member, member representative, or provider?
What organization generally receives external review requests?
The applicable Department of Insurance.
(Utah Insurance Department ,Idaho Department of Insurance, Nevada Department of Insurance, ETC..)
What team receives MAC Appeal submissions from pharmacies?
The Pharmacy Networks Team.
Under Utah law, most MAC Appeals are processed within how many days?
14 days
If a MAC Appeal doesn't meet the required criteria, it may be denied, and a lower-cost alternative NDC may be suggested.
NO CAP!