Page 36 - member_kit_additional_pages

Basic HTML Version

2
The Member, their Authorized Representative or their practitioner may start the Appeal
Process by sending a request in writing to:
Alliance, Attention: Appeals &
Grievance Department, 2850 West Grand Boulevard, Detroit, MI 48202. Members
may submit the completed Appeal document by fax to: (313) 664-5866 or in
person at the Detroit office location: 2850 West Grand Boulevard or at the
Southfield office location: 21700 Northwestern Highway, Southfield, MI 48075.
Members should include any additional information such as:
Medical evaluation report
Medical record
Other important facts to support the request
Once we receive the Appeal, the Appeals & Grievance Department will send a letter
acknowledging that we have accepted the Appeal. Our Appeal policy allows Alliance
thirty (30)
calendar days
to make a final determination for Individual Plan Members.
Individual Members have a one-level internal Appeal Process. Group Plan Members
have a two-step Appeal Process and may appeal at two separate internal levels. For
Group Members, Alliance has
fifteen (15)
calendar days
to make a decision at each
level. Group plan Members may file a written request for a 2
nd
Level Internal Appeal
within
sixty (60) calendar days
from the date of the 1
st
Level Appeal decision.
If an Individual Member or their Authorized Representative is not satisfied with the final
decision once the Internal Appeal Process has been exhausted, they have the option to
External Review. The Group Member, the Member’s Authorized Representative or the
Member’s practitioner have the option to present the 2
nd
Level Appeal in person, by
conference call or through the use of other advanced technology, to the Appeals
Committee. We will provide copies of the file, which includes documents, records and
other information relevant to the Appeal and allowed by law to be disclosed. This
information will be provided at no cost to the member. This information may be
requested at any time.
Due to unforeseen circumstances, Alliance may request an extension of time, up to ten
(10) additional days, if Alliance has not received necessary and requested information
from a health care facility or health professional. Additional extensions are available to a
Member upon their request. If the extension exceeds the allowable time frame,
Members can go directly to the
Department of Insurance and Financial Services (DIFS)
and exercise their right for an External. If you are a Member of a Group health plan
subject to ERISA, you may bring a lawsuit under section 502(a) of ERISA. Ask your
employer if you are part of an ERISA group.