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Network Access Plan for Anthem’s Preferred Provider Plans – PPO

PW_034663
Subsections:
At Anthem Blue Cross and Blue Shield, we work hard to help ensure our members have access to a network of providers that will meet their health care needs. This network includes physicians and other health care providers who deliver quality care and who offer convenient office hours and locations. Providers in our network are available to members for a full range of covered health care services to help them stay healthy. 
Providers play an important role in helping us achieve our mission: to improve the lives of the people we serve and the health of our communities. 
Our network access plan describes the process Anthem uses to develop and maintain adequate provider access, which is one of our primary responsibilities to our members. 
 
PPO Network Providers
Anthem’s PPO network is one of the largest PPO networks in Colorado, with over 8,500 providers statewide, including more than 70 hospitals. Our network includes practitioners who provide primary care (internists, family and general practice physicians, and pediatricians); specialists such as allergists, cardiologists, surgeons, physical therapists and home health providers; facilities such as acute care hospitals and ambulatory care centers; and providers of other medical services such as rehabilitation. 
Emergency services are available 24 hours a day, seven days a week. 
 
When a covered service is not available from an in-network provider
Most health care specialty services are available from providers in Anthem’s broad PPO network. However, if our network does not have a provider to deliver a covered benefit, members should contact Anthem customer service to inform us of the need. Anthem will work with the member to find an out-of-network provider within a reasonable geographic distance. 
In such cases, and with Anthem’s prior approval, the benefit is administered as an in-network benefit. Members will not be denied necessary medical care or charged additional expenses because use of an out-of-network provider is required. 
Open-Access PPOs: Choosing a Provider  
Please note: The following section related to Anthem’s PPO provider network, Anthem’s non-PPO participating provider network and out-of-network providers applies to all Anthem PPO members except those with BlueFreedom coverage. BlueFreedom is an “exclusive provider network” EPO product; members on this plan do not have benefits if they go outside the network. Information for BlueFreedom members about choosing a provider can be found here
PPO provider network 
Anthem PPO members have open access and may use any provider for covered services. However, there is a significant financial advantage for members when they use providers in Anthem’s PPO provider network. 
Members pay less for their health care when they use PPO network providers, and Anthem pays a higher percentage of the costs for covered services. For example, when members use a PPO network provider, they may pay a deductible plus 10 percent of the cost of care. When members receive the same care from a provider in Anthem’s non-PPO participating provider network, they may pay a higher deductible and 20 percent of the cost of care. 
Non-PPO participating provider network 
When members use providers in Anthem’s non-PPO participating provider network, they may also limit their out-of-pocket costs, although not as much as when they use providers in our PPO provider network. 
Providers in our non-PPO participating provider network agree to accept Anthem’s maximum benefit allowance as payment in full for covered services. Members pay only their out-of-network deductible and coinsurance. Providers in our non-PPO participating provider network may not bill members for any charges that exceed Anthem’s maximum benefit allowance for covered services. They also agree to file claims for members. 
Out-of-network providers 
Providers who are not in Anthem’s PPO provider network or Anthem’s non-PPO participating provider network are out-of-network providers. They may bill more than Anthem’s maximum benefit allowance for any procedure, and members are responsible for paying the additional charges. Out-of-network providers may bill members directly for these additional charges and may require payment in full. The member must then submit a claim to Anthem for reimbursement up to our maximum benefit allowance under the member’s plan. 
Blue Freedom Members: Choosing a Provider
BlueFreedom EPO members must use providers in Anthem’s PPO network for covered services. Except when authorized or in emergencies, care received from providers in Anthem’s non-PPO participating provider network and from out-of-network providers is not a covered benefit under the member’s BlueFreedom plan.  
However, in a life- or limb-threatening situation that requires immediate medical care to prevent death or serious impairment of health, MEMBERS SHOULD CALL 911 OR IMMEDIATELY GO TO THE NEAREST EMERGENCY FACILITY. 

The remainder of this network access plan applies to all Anthem PPO plan members, including those who have BlueFreedom coverage.

Provider Directory
Anthem’s provider directory lists practitioners who provide primary care (internists, family and general practice physicians, and pediatricians); specialty physicians (e.g., surgeons, allergists, dermatologists, cardiologists and psychiatrists); facilities (acute care hospitals, ambulatory care centers and skilled nursing facilities); and other medical specialty providers (e.g., physical therapists, home health agencies, substance abuse facilities, rehabilitation services and IV therapy laboratories). The provider directory is available by clicking here or by calling our customer service department at the phone number listed on the back of your health plan ID card. In addition to a list of providers, the directory includes information about how to use the network. 
Behavioral Health Services
Before receiving behavioral health and chemical dependency services, PPO members must call our behavioral health service’s toll-free number at 800-424-4014. Behavioral health services representatives then help members find an appropriate in-network provider. A comprehensive directory that lists in-network providers and facilities is also available at anthem.com or by calling our customer service department at the phone number listed on the back of your health plan ID card. 
Financial Protection for PPO Members
All provider contracts with Anthem protect members from unpaid bills if Anthem or a provider in our PPO provider network or non-PPO participating provider network ceases to operate. Providers in Anthem’s PPO provider network and non-PPO participating provider network may not bill the member for services that should have been paid by Anthem. 
Network Adequacy Standards and Monitoring
Anthem’s quality management program establishes standards, or minimum requirements, to help ensure that our members have adequate access to physicians, hospitals and other health care providers.  
Anthem considers many factors in order to identify, evaluate and remedy problems concerning access to care and the continuity and quality of care, including: 
The number of primary care providers compared to the number of members.
The number of frequently seen specialists and sub-specialists compared to the number of members.
The waiting time between a member’s call for an appointment and the appointment time and date.
The office hours and on-call availability of providers.
The volume of technological and specialty services available to serve the needs of members who require covered technologically advanced or specialty care.
 
Anthem monitors and helps ensure compliance with these standards by reviewing reports that assess the size and distribution of the network, evaluating member satisfaction surveys, and developing surveys that focus on monitoring compliance with the standards. 
Anthem developed the adequacy standards described in this network access plan after reviewing national health care resources for guidance on best industry practices. 
We review these standards, or minimum requirements, and monitor compliance annually. We then design action plans to address opportunities for improvement that are identified during the process. This may include working with in-network providers or contracting with out-of-network providers. 

Anthem PPO Network Adequacy Standards  
Definitions of Levels of Medical Care
 
 
Regular or routine medical care  
Comprehensive care that emphasizes prevention, early detection and early treatment of conditions through routine physical exams, immunizations and health education  
 
Urgent medical care  
Care provided for individuals who require immediate medical attention but whose condition is not life-threatening (non-emergency), e.g., high fever, cuts requiring stitches  
 
   
   
 
Level of Care or Service
Anthem PPO Standard
 
Waiting Time for Care from a Physician
 
Regular/routine medical care  
85% of members always and usually get care when needed 
 
Urgent medical care  
75% of members always and usually get care as soon as they need  
 
After-hours medical care (regular or on-call physician)  
Available 24 hours per day, 7 days per week  
 
   
   
 
Access to Anthem Customer Service
 
Average Speed of Answer  
30 seconds or less  
 
Abandonment Rate  
Less than 5%  
 
   
   
 
Waiting Time for Behavioral Health Care
 
Routine medical care  
Outpatient Therapist (non-MD)
Prescribing Providers (MD/DO) 
10 days  
Urgent medical care  
Outpatient Therapists (non-MD) 
Prescribing Providers (MD/DO) 
48 hours  
Emergency care, non-life threatening  
Outpatient Therapists (non-MD) 
Prescribing Providers (MD/DO) 
Within 6 hours  
After Hours
Outpatient Therapists (non-MD)
Prescribing Providers (MD/DO) 
85% of providers have after-hours 
   
Access to Behavioral Health Care
Average speed of answer  
Less than 30 seconds  
Abandonment rate  
Less than 3%  
Number of Providers Compared to the Number of Members
 
Internists, family and general practice physicians, and pediatricians  
20 providers per 10,000 members  
 
OB/GYNs  
2.9 Providers per 10,000 members  
 
Orthopedic Specialists/Surgeons  
0.6 Providers per 10,000 members  
 
General Surgeons  
0.7 Providers per 10,000 members  
 
Cardiologists  
0.5 Providers per 10,000 members  
 
Psychiatrists  
2.0 providers per 10,000 members  
 
Non-MD Behavioral Health 
8.0 providers per 10,000 members  
 
 
Distance Members Have to Travel to Reach a Provider
PCPs – urban counties*  
2 providers in 20 miles  
PCPs – rural counties **  
2 providers in 60 miles  
All specialists – urban counties*  
2 providers in 45 miles  
All specialists – rural counties**  
1 provider in 100 miles  
Behavioral Health – specialists (MD and non-MD practitioner) – urban counties* 
1 provider within 10 miles 
Behavioral Health – specialists (MD and non-MD practitioner) – rural counties** 
1 provider within 40 miles 
Hospitals – urban counties*  
1 provider in 30 miles  
Hospitals – rural counties**  
1 provider in 60 miles  
Behavioral Health – hospitals – urban counties* 
1 hospital within 25 miles 
Behavioral Health – hospitals – rural counties** 
1 hospital within 45 miles 
Pharmacies – urban counties 
1 provider in 3 miles  
Pharmacies – suburban counties 
1 provider in 5 miles 
Pharmacies – rural counties 
1 provider in 15 miles  
Assisting Members with Special Needs
Transition of care 
When benefits end while a member still needs care, Anthem assists with the transition by offering to educate the member about alternatives for continuing care and, as appropriate, how to obtain care. Anthem’s clinical care coordinator completes this process. 
Continuity of care 
When members join or leave Anthem, they may have to change providers. Anthem provides coverage for continuing care that was in progress before a new member’s effective date with Anthem, if the services were in-network under the prior carrier’s plan. Benefits are also allowed if Anthem’s network experiences significant disruption due to provider contract terminations. 
Continuing care may be allowed for: 
A pregnant member who is in the second or third trimester of pregnancy, through the postpartum timeframe.
Elective surgeries approved by the prior carrier’s preauthorization process, if the surgery was previously scheduled and if Anthem determines that it is a covered benefit.
Ongoing treatment for an acute inpatient episode or chronic condition.
Home health care, home IV therapy and durable medical equipment approved by the prior carrier or medical management group.
Rehabilitation programs.
Life-threatening conditions.
Terminal illnesses.
 
In these situations, Anthem, the primary care physician, the specialist and the member work together. They try to complete treatment with the existing providers or transfer care to providers in Anthem’s network. 
If Anthem has applied a pre-existing condition limitation period, continuing coverage of service may not be available. 
Anthem also cooperates with other health plans when a member leaves Anthem. 
Members with physical and mental disabilities (needs)
The provider directory indicates provider locations that are accessible to members with disabilities. Arrangements will be made for members who require other assistance, such as special communication tools. Anthem customer service representatives are available to assist with members’ special needs. 
Non-English speaking members
Providers who speak languages in addition to English are identified in Anthem’s provider directory. When non-English-speaking members call our customer service department, we communicate with them through a translation connection with AT&T. The customer service representative connects the member with a translator from AT&T via teleconference to complete the service call. This allows us to accommodate 140 different languages. 
Some member materials are available in Spanish and are furnished on request. We continually strive to identify the unique needs of our members and address those needs through our provider networks and through company initiatives. 
Quality Management
Anthem has a quality management program designed to evaluate the quality, appropriateness and outcomes of care and services. We also monitor how care and services are delivered to Anthem members. During this process, we place emphasis on identifying opportunities for improvement and problem-solving. 
The program is directed by the West Region Strategic Planning Committee. The Quality Management Committee (QMC), which includes external network physicians along with Anthem’s quality department staff, provides clinical expertise and recommendations for the implementation of the QM program. 
We use standards developed by national organizations for developing, maintaining and reporting quality management program activities. 
Programs to Improve Member Health Care Needs and Health Outcomes
The quality management program uses a structured process to evaluate and improve the program, including: 
Reviewing important aspects of care and service.
Identifying opportunities for improvement.
Designing improvement initiatives.
Implementing the initiatives.
Evaluating the effect of the initiatives.
 
One important aspect of this process includes analyzing the specific health care needs of Anthem members. By reviewing claims data, surveys and member demographic data (chronic diseases, cultural backgrounds, etc.), Anthem identifies certain populations, such as members who have diabetes or asthma, and targets programs to improve the health of those members. 
We also review specific populations to help ensure that our network includes an adequate number of providers, including specialists, to serve those populations. 
Anthem places a priority on preventing illness and delivering the appropriate care in the appropriate setting. For example, women who do not receive their annual cervical cancer screening are identified by claims records and are reminded of the importance of the screening via phone or mail. 
Membership surveys
Anthem conducts several member surveys. These surveys help us understand how members feel about various aspects of their health care benefits plan, such as the waiting time for appointments, their satisfaction with the care received and the number of providers in our network. 
The surveys are used to identify opportunities for improvement. We then build action plans around these opportunities. 
Communicating with Members
This network access plan is one way we inform members about Anthem’s provider network. We also communicate information about our provider network and the health plan’s services and features through the following: certificates, customer services, newsletters, and the website. 
Certificate

Members enrolling in Anthem’s PPO health care benefits plan have access to their certificate via Anthem’s website. This certificate describes the benefits available to the member and how to use those benefits. It also describes how Anthem’s grievance procedures, the availability of specialty medical services and Anthem’s process for preauthorizing medical care. New and renewing members receive information about how to access their certificate with their health plan ID card(s).

Additional copies of the certificate are available by calling our Customer Service at the phone number listed on the back of your health plan ID card.

Customer service

Anthem customer service representatives are available to assist members. To help them better serve our customers, these representatives receive specialized training in areas such as service skills, problem-solving, our benefit plans and our provider networks. Our representatives are available from Monday through Friday, at the phone number listed on the back of your health plan ID card.

 
Member Concerns (Clinical Grievance, Complaints and Appeals)
Members who have a concern about service received from Anthem or about the care or services received from a provider in the Anthem network may call Anthem 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 Anthem’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 Anthem’s service 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 Anthem’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: 
Anthem Blue Cross and Blue Shield
Customer Service Department
P.O. Box 5747
Denver, CO 80217-5747 
If the member is not satisfied with the resolution of the member’s concern by the Anthem Customer Service representative, 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 Anthem’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 Anthem encourages members to file appeals within 60 calendar days of the adverse benefit determination, Anthem 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
Appeals Department
700 Broadway CAT 0430
Denver, CO 80273-0001 
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. Anthem 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 Anthem on the member’s behalf. When a member designates a representative to file an appeal on the member’s behalf, the member must provide Anthem 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 Colorado 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, Anthem 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 Anthem 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. 
Anthem 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 (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. Anthem 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 Anthem’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 Anthem, upon request, copies of all documents, records and other information Anthem 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 Anthem at least 5 days prior to the date of the review meeting); (v) if applicable, ask questions of any representative of Anthem 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 Anthem will send a copy of the Level 2 appeal decision.  
The panel of reviewers will include a minimum of three people and may be composed of Anthem associates who have appropriate professional expertise. 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. 
Anthem will schedule and hold the Level 2 appeal meeting within 60 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 Anthem 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 Anthem 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, Anthem shall make an audio or video recording of the review unless neither the member nor Anthem 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 Anthem 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, Anthem 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. Anthem 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 Anthem 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. Anthem 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. The member must have exhausted the Level 1 Appeal, but may make such a request either after, or instead of, exercising the right to file a Voluntary Level 2 Appeal. Independent External Review Appeals are conducted by independent external review entities, which are selected by the Colorado 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 Anthem’s Customer Service Department. The request must be made to Anthem within 60 calendar days after the date of receipt of notice of Anthem’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 Anthem 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 Anthem 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 appeal are voluntary and are not required before pursuing legal action. 
Arbitration procedures – If any party involved is not satisfied with Anthem’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 Anthem, 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 Anthem. 
Legal action – Before a member takes legal action on a claim decision: 
The member must 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.
 
The Anthem Blue Cross and Blue Shield network access plan is designed to assist our members in understanding their benefits and how to access the providers and hospitals available to them through Anthem’s PPO health care benefits plans. If you have any questions about your plan or the information in this document, please call customer service at the phone number listed on the back of your health plan ID card. 
©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