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Complaints and Appeals

PW_006776

Grievance and Appeals for HMO Nevada Members

 
Members Concerns (Clinical Grievance, Complaints and Appeals)  
Members who have a concern about services received from HMO Nevada or about the care or services received from a provider in the HMO Nevada network may call HMO Nevada customer service at the phone number listed on the back of your health plan ID card.  
 
Clinical Grievance  
A clinical grievance occurs if you have an issue or concern about the quality or services you receive from a provider or facility in HMO Nevada’s network. The quality management department strives to resolve clinical grievances fairly and quickly. We will work to clear up any confusion, settle your concerns and make sure appropriate action is taken.  
 
To Initiate A Clinical Grievance:  
A member may send a written clinical grievance to the following address:  
 
Anthem Blue Cross (Anthem)
PO Box 4310
Woodland Hills, CA 91367  
 
Anthem’s quality management department will acknowledge receipt of and investigate the member’s clinical grievance. The quality management department treats each clinical grievance investigation in a strictly confidential manner.  
 
Complaint  
A problem concerning any aspect of HMO Nevada’s services or claims processing is a complaint. A Customer Service representative will work with the member to clear up any confusion and resolve difficulties.  
 
To Initiate A Complaint:  
If a member has a complaint about any aspect of HMO Nevada’s service or claims processing, the member should contact Anthem’s Customer Service Department. A Customer Service representative will work to clear up any confusion and resolve the member’s concerns. A member may submit a written complaint to the following address:  
 
HMO Nevada
Customer Service Department
P.O. Box 5747
Denver, CO 80217-5747  
 
If a member is not satisfied with the information provided by the HMO Nevada Customer Service representative during resolution of a complaint, the member may file an appeal, as explained below.  
 
Appeal  
Members may go through the complaint process before filing an appeal or may choose to file an appeal without first going through the complaint process. There are two types of appeals: a utilization review (UR) appeal and a non-utilization review (non-UR) appeal. Non-UR appeals include appeals about certificate exclusions, benefit maximums and other non-UR claims denials.  
 
To File an Appeal:  
Where HMO Nevada’s actions have resulted in an adverse benefit determination (e.g. a claim for services or request for preauthorization which has been denied in whole or in part), the member may appeal the adverse benefit determination. An appeal may be filed with or without first submitting a complaint. The member’s appeal must be in writing (except for expedited utilization review appeals). While HMO Nevada encourages members to file appeals within 60 calendar days of the adverse benefit determination, HMO Nevada must receive the member’s written appeal within 180 calendar days of the member’s receipt of the adverse benefit determination. Members may send written appeals to the following address:  
 
Anthem Blue Cross and Blue Shield
Attn: Member Appeals
P.O. Box 10330
5250 South Virginia Street
Reno, NV 89520
Fax: (775) 448-4277  
 
In the written appeal, the member must state plainly the reason(s) the member believes the claim or requested service or supply should not have been denied. The member has the right, and is encouraged to submit written comments, documents, records or other information relevant to the appeal. HMO Nevada will assign an employee to assist the member in the appeal process.  
Members may designate a representative (e.g., the member’s physician, counsel, advocate or anyone else of the member's choosing) to file or pursue any level of appeal review with HMO Nevada on the member’s behalf. When a member designates a representative to file an appeal on the member’s behalf, the member must provide HMO Nevada with this designation in writing.  
The member may access two internal levels of appeal. Additionally, in the case of a benefit denial based on utilization review, an independent external review appeal is available to the member.  
 

Utilization review” means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review. For the purposes of this Guide, utilization review shall also include reviews for the purpose of determining coverage based on whether or not a procedure or treatment is considered experimental or investigational in a given circumstance, and reviews of a member’s medical circumstances when necessary to determine if an exclusion applies in a given situation. A denial on the basis that the treatment, drug or device is excluded by the member’s policy will be considered a denial based on utilization review, provided the member presents evidence from a medical professional licensed under the Nevada Medical or Dental Practice law, that there is a reasonable medical basis that the contractual exclusion does not apply.

 
Level 1 Appeal: During the first level of appeal, HMO Nevada appoints an internal person or persons not involved in the initial determination to review the denial of the claim or requested service or supply. A person who was previously involved with the denial may answer questions. A Level 1 appeal involving utilization review will be evaluated by a physician who will consult with an appropriate clinical peer(s), unless the reviewing physician is a clinical peer.  
 

Clinical peer” means a physician or other health care professional who holds a non-restricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review.

 
Where the benefit in question was denied due to a contractual exclusion, in order to secure a Level 1 appeal involving utilization review, the member must be able to provide evidence from a medical professional that there is a reasonable medical basis that the exclusion does not apply. In such an event, the determination shall be made on the basis of whether the contractual exclusion applies to the denied benefit.  
The member does not have the right to attend the Level 1 appeal, but the member is entitled to submit written comments, documents, records and other material relating to the request for benefits for the reviewer(s) to consider. The member may also identify providers to whom HMO Nevada shall send a copy of the Level 1 appeal decision. The member also has the right to receive, upon request and free of charge, reasonable access to and copies of all documents, records and other information relevant to the member’s request for benefits. In conducting the Level 1 appeal, the reviewer(s) will consider all of the comments, documents, records and other information regarding the request for services submitted by the member, regardless of whether that information was submitted or considered in connection with the initial adverse benefit determination.  
HMO Nevada will notify the member of the outcome of a Level 1 appeal involving utilization review within 30 calendar days of receipt of the appeal request. Level 1 appeals which do not involve utilization review will be resolved within 30 calendar days of receipt of the appeal request. (60 calendar days for post-service claims) of receipt of the appeal request. The appeal decision timeframes may be extended if the member requests or voluntarily agrees to the extension.  
 
Voluntary Level 2 Appeal: If the adverse benefit determination has not been resolved to the member’s satisfaction under the Level 1 appeal process, the member has the option (but not the obligation) to utilize a Level 2 internal appeal. HMO Nevada will provide the covered person, upon request, sufficient information relating to the voluntary Level 2 review to enable the member to make an informed judgment about whether to submit the adverse determination to the Level 2 appeal review. The member’s decision to pursue, or not pursue, a Level 2 appeal will have no effect on the member’s right to any other benefit under the insurance policy or certificate.  
If the member chooses to pursue a Level 2 appeal, the Level 2 appeal must be requested within 60 calendar days after the member receives HMO Nevada’s decision of the Level 1 appeal. In connection with a Level 2 appeal, the member has the right to (i) request the opportunity to appear in person or by teleconference before the Level 2 appeal panel; (ii) prepare in advance for the appeal review and receive from HMO Nevada, upon request, copies of all documents, records and other information HMO Nevada intends to present at the Level 2 appeal review, at least 5 days prior to the review;; (iii) present the member’s case to the appeal panel; (iv) submit written comments, documents, records and other material relating to the request for benefits for the appeal panel to consider when conducting the review both before and, if applicable, at the appeal meeting (a copy of the materials the member plans to present should be provided to HMO Nevada at least 5 days prior to the date of the review meeting); (v) if applicable, ask questions of any representative of HMO Nevada or the review panel; (vi) be assisted or represented at the appeal meeting by an individual of the member’s choice and bring counsel, advocates and healthcare professionals to the appeal meeting; and (vii) identify any providers to whom HMO Nevada will send a copy of the Level 2 appeal decision.  
The panel of reviewers will include a minimum of three people. The majority of the Level 2 Appeal Board are members who receive health care benefits from Anthem. A majority of the panel will be comprised of persons who were not previously involved in the dispute; however, a person who was previously involved with the dispute may be a member of the panel or appear before the panel to present information or answer questions. In the case of utilization review appeals, the person(s) reviewing the appeal will be health care professional(s) who have appropriate expertise in relation to the case presented by the member. Such reviewing health care professional(s) will not have been involved in the member’s appeal review process or the member’s care previously, and will not have a direct financial interest in the case or the outcome of the review.  
HMO Nevada will schedule and hold the Level 2 appeal meeting within 30 days of receiving the member’s request for a Level 2 appeal. The member will be notified in writing, at least 20 days prior to the Level 2 appeal review date. If HMO Nevada wishes to have an attorney to represent its interests at the meeting, it will notify the member that an attorney will be present, and advise the member that the member may wish to obtain legal representation of his/her own. If the member intends to have an attorney represent the member’s interests at the meeting, the member should notify HMO Nevada at least 7 days prior to the meeting, where practicable. In addition, in connection with the Level 2 appeal of a denial involving utilization review, HMO Nevada shall make an audio or video recording of the review unless neither the member nor HMO Nevada wants the recording made and this recording will be made available to the member. If there is an external review of the Level 2 appeal decision, the recording will, at the request of either party, be included in the material provided by HMO Nevada to the reviewing entity.  
In conducting the review, the appeal panel will consider all of the comments, documents, records and other information regarding the request for services submitted by the member, regardless of whether that information was submitted or considered in connection with the Level 1 appeal decision. Where the Level 2 appeal concerns a denial due to a contractual exclusion and involves utilization review, the determination shall be made on the basis of whether the contractual exclusion applies to the denied benefit.  
Unless the member requests otherwise in connection with a Level 2 appeal involving utilization review, HMO Nevada will not allow an audio or videotape recording of the appeal meeting to be made. After private deliberation, the appeal panel will issue a written decision, which will be provided to the member within 7, days of completing the appeal meeting.  
 
Expedited Appeals: A member or a member’s representative (including the member’s practitioner) has the right to request an expedited review if handling the appeal as a standard appeal: (1) could seriously jeopardize the member’s life, health or ability to regain maximum function; (2) would, in the opinion of a physician with knowledge of the member’s medical condition, subject the member to severe pain that cannot be adequately managed without the service or treatment in question; or (3) would, for persons with a disability, create an imminent and substantial limitation on their existing ability to live independently. In addition, expedited review is granted to all requests concerning admissions, continued stay or other health care services for a member who has received emergency services but who has not been discharged from a facility. HMO Nevada will not provide an expedited review for retrospective denials. The request for Expedited appeal may be oral or made in writing.  
Expedited appeals will be evaluated by an appropriate clinical peer or peers not involved in the initial denial. The member does not have the right to attend the Expedited appeal, but the member is entitled to submit written comments, documents, records and other material relating to the request for benefits for the reviewer(s) to consider. The member may also identify providers to whom HMO Nevada shall send a copy of the expedited appeal decision. The member also has the right to receive, upon request and free of charge, reasonable access to and copies of all documents, records and other information relevant to the member’s request for benefits. In conducting the Expedited appeal, the reviewer(s) will consider all of the comments, documents, records and other information regarding the request for services submitted by the member, regardless of whether that information was submitted or considered in connection with the initial adverse benefit determination. The decision will be expeditiously made, and the member or representative will be notified of the decision within 72 hours of the request. HMO Nevada will notify the member and the member’s provider via phone or e-mail and within 3 days, follow up in writing regarding the determination of the Expedited appeal. If the Expedited appeal does not resolve the adverse benefit determination to the member’s satisfaction, the member may pursue either a Voluntary Level 2 Appeal as noted above or an Independent External Review Appeal.  
 
Independent External Review Appeals: When the adverse benefit determination involves utilization review, the member may request an Independent External Review Appeal. Independent External Review Appeals are available only where all of the following conditions have been met: (1) the claim or requested service or supply was denied, in whole or in part on the basis that it is not medically necessary or appropriate or is experimental or investigational; (2) the denial of the claim will require the member to pay $500 or more; and (3) the claim has been appealed through Anthem’s Level 2 Appeal process (unless Anthem agrees to submit the appeal to external review prior to the member exhausting the Level 1 and Level 2 Appeal process). Independent External Review Appeals are conducted by independent external review entities, which are selected by the Nevada Division of Insurance. To request an Independent External Review Appeal, the member or member’s representative must complete and submit a written request on a Request for Independent External Review of Carrier’s Final Adverse Determination Form, which is available through HMO Nevada’s Customer Service Department. The request must be made to HMO Nevada within 60 calendar days after the date of receipt of notice of HMO Nevada’s final appeal denial. The Division of Insurance will assign an independent external review entity to conduct the review. The independent reviewer’s decision will be made within 30 business days after HMO Nevada receives a request for such a review. This timeframe may be extended up to 10 business days for the consideration of additional material, if requested by the independent external review entity.  
 
Expedited Independent External Review Appeals: A member or a member’s representative may request an expedited independent external review appeal if the member has a medical condition for which the timeframe for a standard independent external review appeal would seriously jeopardize the member’s life or health; jeopardize the member’s ability to regain maximum function; or, for persons with a disability, create an imminent and substantial limitation on the member’s existing ability to live independently. The member’s request must include a physician’s certification that the member’s medical condition meets the criteria for an expedited independent external review appeal. The request must be made on the form referenced in the paragraph above. Determinations will be made by the independent external review entity within seven business days after HMO Nevada receives a request for an expedited independent external review appeal. This timeframe may be extended for an additional five business days for the consideration of additional information, if requested by the independent external review entity. An expedited independent external review appeal may not be provided for retrospective denials.  
Before legal action is taken on a claim decision, members must request a Level 1 appeal. Subsequent levels of appeals are voluntary and are not required before pursuing legal action.  
 
Arbitration procedures – If any party involved is not satisfied with HMO Nevada’s decision as explained under the appeal procedures heading, the party may pursue the remedies available under the Employee Retirement Income Security Act of 1974 (ERISA) and/or binding arbitration, whichever is applicable to the member’s health care benefits plan. Any party alleging a claim against HMO Nevada, including a claim for denial of benefits or coverage, must follow the process described under the appeal procedures heading before instituting a legal proceeding, suit or arbitration against HMO Nevada.  
 
Legal action – Before a member takes legal action on a claim decision: 
The member must first follow the Level 1 appeal process outlined under the appeal procedures heading. Subsequent levels of appeal are voluntary and are not required before pursuing legal action.
The member must meet all requirements of the member’s certificate.
No action in law or equity will be brought to recover before the expiration of 60 calendar days after written proof of loss has been filed according to the requirements of the member’s certificate.
No such action will be brought at all unless it is brought within three years of the time within which written proof of loss has been filed as required by the member’s certificate.
 
 
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use