Page 41 - PA_HMO_Member_Kit

Basic HTML Version

HAP-GRV 9/2013
2
Once we receive the Appeal, the Grievance department will send a letter acknowledging
that we have accepted the Appeal. Our Appeal policy allows HAP
thirty (30)
calendar
days to make a final determination for Individual Plan Members. Individual Members
have a one-step Appeal Process. Group Plan Members have a two-step Appeal
Process and may Appeal at two separate internal levels. For Group Members, HAP has
fifteen (15) calendar days to make a decision at each level.
If a Member approves HAP’s request for an extension of time, HAP may be allowed up
to ten (10) additional days for review if HAP 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 we go past the allowable time frame,
Members can go straight to the State and use their right for an external review or 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.
We also offer an expedited appeal Process where we will make a decision within 72
hours. Members may make a request for an Expedited Appeal if they believe that
waiting for the routine timeframe for an internal appeal would seriously threaten them,
their health or their ability to regain maximum function. We will ask a physician to
review the request and the physician will determine if the Member’s medical condition
needs a decision within 72 hours. If the Member’s physician makes the request for an
Expedited Appeal or indicates that the Member needs an Expedited Appeal, we will
provide the Member with a decision within 72 hours.
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.
Members may request and receive, at no cost, reasonable access to copies of
documents, records and other information relevant to their Appeal.
During the Internal Appeal Process, Members or their Authorized Representative have
the option to present their Appeal in person to the HAP Appeal Committee. Group Plan
Members have this option at the 2
nd
level Appeal. In order for Members to present their
Appeal before the Appeals Committee, we will provide them with copies of the file which
includes documents, records and other information relevant to the Appeal and allowed
by law.
At any time, Members may submit a request for reasonable access to copies of
documents, records and other information relevant to the Appeal and allowed by law.
This information will be provided at no cost to our Members.
A health care practitioner who has appropriate training and experience in the field of
medicine involved in your case will review the Appeal when the Initial Adverse Benefit
Determination was based on medical necessity.