A pre-service appeal is a request to change a denial of coverage for a planned health care service. The member’s rights in the member’s benefit plan govern this process. To submit a normal pre-service appeal request, follow the information in the pre- service denial letter. A peer-to-peer review is highly recommended before you file a pre-service appeal.
Expedited or urgent appeals
If you have already provided the service, an expedited or urgent appeal is not available. Submit a claim based on the service provided. See the appeal section for more information.
To request an urgent pre-service appeal on behalf of the member, follow the information in the pre-service denial letter. We consider requests urgent when:
The standard review time frame risks the life or health of the member.
The member’s ability to regain maximum function is jeopardized.
The member’s severe pain is not able to be managed without the care or treatment requested.
Medical records request submission time frame
If we request medical records to process an appeal, you must provide the information within the following time frames. This includes providing a copy of the denial notice.
Expedited appeal: Within 2 hours1 of receipt of request
Standard appeal: Within 24 hours1 of receipt of request
1 Time frames may change based on applicable law or your Agreement.