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Once we receive the Appeal, the 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-step 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.
If a Member approves Alliance’s request for an extension of time, Alliance may be
allowed up to ten (10) additional days for review 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 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 Alliance 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.
AHL-GRV 9/2013
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