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GROUP AND INDIVIDUAL APPEAL AND GRIEVANCE POLICY
PURPOSE
To provide any Alliance Health and Life Insurance Company (Alliance) Member or the
Member’s Authorized Representative a receives an Adverse Organization
Determination (“Appeal Process”) or formalized course of action when the Member is
not satisfied or feels wronged by the services, benefits and/or policies and procedures
of Alliance or its providers (“Grievance Process”) . This policy applies to Pre-Service
(care that has not been received), Post-Service (care that has already been received),
Expedited (care that is urgent) and Concurrent (care while Member is an in-patient)
Appeals and Grievances.
SCOPE
This policy applies to all Group or Individual (EPO, PPO, PA and Medicare
Supplemental) product line Appeals and Grievances. This policy does not apply to
FEHBP, Medicare Advantage, Medicaid or Self-Funded products, which have their own
policies.
POLICY
The Appeal Process allows Members to file an Appeal when an initial denial (
Adverse
Organization Determination
) for payment or services a Member believes he or she is
entitled to receive, including delay in providing, arranging for or approving the health
care services (such that a delay would adversely affect the health of the Member) or on
any amounts the Member must pay.
The Grievance Process allows Group and Individual plan Members to file a complaint or
dispute (other than an A
dverse Organization Determination)
expressing dissatisfaction
with the manner in which the Plan provides health care services, regardless of whether
any remedial action can be taken. A Member or their Authorized Representative may
make the complaint or dispute, either orally or in writing, to the plan, provider or facility.
Members may receive this policy in an alternative language (Arabic, Farsi, Spanish or
another language) by contacting our Client Services Department at the number listed
within this policy.
INTERNAL APPEAL PROCESS
A Group Plan or Individual Member may submit an Appeal in writing within
180
calendar days
from the date of the initial denial (Adverse Organization Determination).
Although an Appeal of an Adverse Organization Determination must be in writing,
Members who are unable to submit a written Appeal may contact our Client Services
Department for assistance. Alliance will work with the Member to find an alternative
method for the Member to submit an Appeal.