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EXTERNAL REVIEW PROCESS
If a Member is still not satisfied with the final decision after the Internal Appeal Process
has been exhausted or Alliance has gone past the allowed review period, the Member
can ask for an External Independent Review that is allowed under the Patient’s Right to
Independent Review Act (PRIRA). Members can request an External Review by
contacting the Director of the DIFS within
sixty (60) calendar days
of exhausting
Alliance’s Internal Appeal Process at:
Department of Insurance and Financial Services
Healthcare Appeals Section
Office of General Counsel
611 Ottawa, Third Floor
P.O. Box 30220
Lansing, MI 48909-7720
Members can also call the Director toll-free at (877) 999-6442. Alliance will
automatically provide Members with the
FIS 0018 (8/12) - Health Care Request for
External Review Form
. This form is necessary to request an External Review.
EXPEDITED APPEAL PROCESS
A Member may request an Expedited Appeal verbally or in writing in which case a
decision will be made within 72 hours. If a Member requests an Expedited Appeal, a
Member or the Member’s Authorized Representative may concurrently request an
External Review from DIFS. The internal Expedited Appeal may be discontinued when
an External Review is accepted for by DIFS.
Alliance will automatically grant an Expedited Appeal for all requests concerning
admissions, continued stays or other health care services for a Member who has
received emergency services but has not been discharged from a facility.
Alliance will automatically consider a Pre-Service or Concurrent Claims Appeal to be an
Expedited Appeal if a practitioner with knowledge of the Member’s medical condition
submits the Appeal on the Member’s behalf and informs Alliance that the Appeal is
urgent. Alliance will notify both the Member and the practitioner of the decision. Alliance
will notify the practitioner and Member verbally within 72 hours. Alliance will send a
follow-up written notification to the Member and practitioner no later than
three (3)
calendar days
after the verbal notice.
Members are allowed to have continued coverage during the Expedited Appeal Process
for
approved
ongoing courses of treatment pending the outcome of an Internal Appeal.
OTHER RIGHTS
If you are a Member of a Group Health Plan subject to ERISA, you may bring a lawsuit
under section 502(a) of ERISA if you have exhausted the Alliance Internal Appeal
Process. Ask your employer if you are part of an ERISA group.