Right to an External Review of Claims

For certain types of denied claims (e.g., a claim denied for a lack of medical necessity), the law provides that a claimant may be entitled to request an independent, external review after the Plan’s final internal adverse benefit determination.  A claimant may contact the applicable Plan Vendor with any questions on his or her rights to external review by an independent organization. After a final internal adverse benefit determination, the applicable Plan Vendor will advise the claimant of any right the claimant may have to an independent external review and the procedure to request such a review. If the claimant believes his or her situation is urgent (generally one in which the claimant’s health may be in serious jeopardy or in the opinion of  the claimant’s physician, the claimant may experience pain that cannot be adequately controlled while the claimant waits for a decision on the external review of his or her claim), the claimant may request an expedited appeal by contacting the applicable Plan Vendor for more information.

The claimant or someone the claimant names to act for him or her (the claimant’s authorized representative) may file a request for external review. A claimant may contact the applicable Plan Vendor for information on how to designate an authorized representative.