Provider/Member Rights and Appeals
PW_034579
Subsections:
Policy Statement
Provider-carrier appeals must be submitted to Anthem’s provider appeals department in writing or on the Provider Dispute Resolution Form. Providers have one year from the date of the original explanation of benefits (EOB) or remittance advice (RA) to dispute a claims adjudication action. This policy does not apply to routine provider inquiries that Anthem resolves in a timely fashion through existing informal processes (i.e., through customer service or submission of a Claim Action Request Form). The Provider-carrier appeal process is available for administrative and payment issues only. Members may appeal utilization review decisions in accordance with the member appeals process. Anthem will make a determination within 60 calendar days of receipt of all the necessary information, unless the timeframe is extended by mutual agreement; in those cases, Anthem will send written notification of the outcome to the Provider by the mutually agreed upon date.
When Anthem does not receive all the information necessary to make a decision, Anthem will send the Provider the following within 30 calendar days of our receipt of the appeal request: 1) written notice of what is required; 2) the date the information is due; and 3) a reminder that failure to send the information within the allowed 30-day time frame will result in closure of the appeal with no further review. Anthem will notify the Provider that further consideration of the closed appeal must begin with a new request. This policy complies with Colorado Insurance Regulation 4-2-23.
Necessary Information
Necessary information consists of 1) each applicable date of service; 2) the subscriber or member name; 3) the patient name; 4) the subscriber or member number; 5) the Provider name; 6) the Provider tax identification number; 7) the dollar amount in dispute, if applicable; 8) the Provider position statement explaining the nature of the dispute; and 9) supporting documentation when necessary, e.g., medical records, proof of timely filing.
Designating a Provider Representative and Face-to-face Opportunity
Anthem offers Providers the opportunity in the appeal process to designate a Provider representative and will allow the Provider or the Provider’s representative the opportunity to present the Provider’s rationale for the appeal request in person. When the Provider determines that a face-to-face meeting is not practical, Anthem offers alternative methods such as a teleconference. Anthem may require a signed confidentiality agreement from the Provider’s representative as a condition to participating in the appeal process.
Notification Requirements
For Provider-carrier appeal requests where all the necessary information is provided, Anthem will send written confirmation of receipt within 30 days of the dispute request and will include the following: 1) a description of the appeal resolution procedures and timeframes; 2) the procedures and timeframes for the Provider or the Provider’s representative to present the rationale for the appeal request; and 3) the date by which Anthem will resolve the appeal. When the appeal request is resolved in favor of the Provider in accordance with this policy within 30 days, the notice of favorable resolution will act as written confirmation.
If the determination is not in favor of the Provider, the written notification will include the following: 1) the principle reason(s) for the decision; 2) the names and titles of the parties who evaluated the appeal and, if the decision was based on review of medical documentation, the qualifying credentials of the parties; 3) a statement of the reviewers’ understanding of the reason for the appeal; 4) the reviewers’ decision in clear terms and the rationale for the decision; and 5) the reference to the evidence or documentation used as a basis for the decision.
Providers have a single-step internal appeal’s process. Based on the type of issue being appealed, Anthem’s provider advocates and medical directors, its medical review, medical policy and provider contracting departments, and/or other appropriate business areas may review appeal requests.
Please use the Provider Dispute Resolution Form for all Provider-carrier appeal requests. Send all requests to Anthem Provider Appeals, P.O. Box 5747, Denver, CO 80217-5747 Billing Dispute External Review Process
The billing dispute external review process is available to physicians who are class members of the Shane-Thomas Managed Care Settlement Agreement (“the Settlement Agreement”) and physician groups comprised of such physicians. The process is intended to resolve:
 | Disputes over the application of Anthem’s coding, payment rules and methodologies for fee-for-service claims to patient specific factual situations. |
| Disputes related to whether Anthem has complied with the provisions of the Settlement Agreement, requiring a physician to submit records in connection with a claim for payment (either before or after payment). |
Please note: Physicians and physicians' groups must exhaust Anthem’s internal appeal/review process for billing disputes before submitting a dispute to the billing dispute external review board. This requirement will be deemed to have been satisfied if Anthem has responded to your appeal, and its response indicates internal review has been exhausted or if there is no notice of Anthem’s decision within 30 calendar days after you have supplied all documentation reasonably needed to complete the internal appeal/review. Physicians and physicians' groups must submit their billing dispute request directly to the BDERB. It must be post-marked no later than 90 calendar days after exhausting Anthem’s internal appeals/review process.
To initiate the external billing dispute external review process, certain criteria must be met, and a fee is required. The requirements are:
| Disputes may be submitted only by a physician who is a member of the Shane-Thomas settlement class or a physician group consisting of such physicians. |
| Anthem’s internal appeals/review process must be exhausted. |
| The amount in dispute (for either a single claim for covered services or multiple claims involving similar issues) must be greater than $500.* |
| The dispute must be filed in writing within 90 calendar days after exhausting Anthem’s internal appeals/review process. |
| The physician or physician group must submit the proper filing fee as shown below. |
*A physician or physician group can submit a dispute with a disputed amount less than $500 to the BDERB if the physician or group intends to submit additional disputes involving similar issues within one year such that the aggregate amount in dispute will exceed $500. The BDERB will defer consideration of the dispute until and unless such additional disputes are submitted.
Filing fees are as follows:
| If the amount in dispute is less than or equal to $1,000, the fee is $50. |
| If the amount in dispute is more than $1,000, the fee is $50 plus 5 percent of the amount by which the amount exceeds $1,000, but in no event more than 50 percent of the cost of the review. |
If the physician prevails, the filing fee will be refunded.
Instructions
Please make sure your submission meets the requirements outlined below. You must be able to answer “Yes” to these questions. ( Note: If this is a dispute about a “records requirement”, please download and complete a copy of the “Request for Dispute of Records Requirement” at www.hmosettlements.com.) | Are you a class member of the Shane-Thomas Managed Care Settlement Agreement? |
| Is the date of service after July 11, 2005? |
| Exhaustion of Anthem’s internal appeals/review: |
 | | Have you filed an internal appeal with Anthem Blue Cross Blue Shield and been notified of the outcome? |
| or |
| | Have you filed an internal appeal about which Anthem has failed to communicate a notice of its decision within 30 calendar days after receiving all documentation reasonably needed to complete the appeal/review? |
| The amount in dispute (the additional amount you believe Anthem should have paid) for the single or multiple claims: |
| | Is the disputed amount of the single or multiple claim(s) submitted at this time more than $500? |
| or |
| | Have you previously filed and deferred consideration of billing disputes involving similar issues within one (1) year, and if so, does the filing of this claim result in an aggregate disputed amount greater than $500? |
| or |
| | If this request is less than $500, but you would like this request to be deferred so you can submit additional billing disputes later? (Note: The filing fee is payable with your first submission.) |
You must submit Anthem’s final appeal letter with your dispute. You must also attach to the Billing Dispute External Review Form and all supporting documentation that you would like to be considered by the billing dispute external review board. Examples of supporting documentation include remittance advice(s) and clinical information.
The billing dispute external review board may request additional documentation from you. Any such additional documentation must be submitted within 30 calendar days of the request.
Dispute Category Example List
The following list contains examples of the types of billing disputes that are eligible for submission to the billing dispute external review process. It is not an exhaustive list of every eligible dispute, but is provided to assist you in submitting eligible disputes for external review. Disputes that are not eligible for this process may still be referred to Anthem’s resolution through the internal appeal process. For example, disputes about the reimbursement rates set by Anthem through its fee schedules or about allowable fee determinations for out of network physicians may be referred to Anthem.
IMEDECS will determine whether your dispute is eligible for review. To help IMEDECS with the determination, please indicate the type of issue that you are raising.
Examples of billing disputes eligible for review if all requirements indicated above are satisfied include:
| Assistant surgeons (includes modifier 82) – eligible/non-eligible |
| Consultation on X-ray examination, written report (CPT© code 76140) |
| Modifier 22 – unusual procedural services |
| Modifier 23 – unusual anesthesia |
| Modifier 24 – unrelated evaluation and management service by the same physician during a post-operative period |
| Modifier 25 – significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service |
| Modifier 51 – multiple procedures |
| Modifier 59 – distinct procedural service |
| Modifier 62 – two surgeons |
| Modifier 66 – surgical teams |
| Therapies – modalities per date of service |
| Reduction of the intensity of an E&M code(s) |
| Reduction of the intensity of a service (other than an E&M code) |
| Other “bundling” edits |
Frequently Asked Questions
Q: When I file a dispute, how quickly will I have a resolution?
A. Once the billing dispute external review board (BDERB) receives your billing dispute, it will evaluate your submission to determine if you have met the requirements. The BDERB will then request verification and documentation from Anthem. Anthem has 30 days to submit documentation to the BDERB. After the BDERB receives all necessary documentation, the BDERB has 30 days to review the billing dispute.
Q: If my billing dispute is decided in my favor, what is the resolution time for Anthem to process the claim for reimbursement?
A: If the billing dispute is decided in the physician’s favor, Anthem will reprocess the claim and send payment to you within 15 days after receipt of notification of the BDERB’S decision.
Q: What is a retained claim?
A: Retained claims are claims that were “in process” as of July 11, 2005. Specifically, a retained claim can be:
| A claim that had been filed with Anthem but had not been finally adjudicated as of July 11, 2005; or |
| A claim that has not yet been filed with Anthem, but for which the contractual period allowed for filing has not expired. |
A claim is considered finally adjudicated when Anthem’s internal appeals/review process has been completed.
Q: Can I submit a dispute about a retained claim to the BDERB?
A: Billing disputes about retained claims can be submitted to the BDERB provided they are submitted before the later of 1) May 4, 2006; or 2) 90 days after you exhaust Anthem’s internal appeals process.
Q: What do I do if I want to challenge a request for records?
A: If the dispute relates to Anthem’s requirement that records be submitted (either before or after payment), the physician or physician group may elect not to utilize Anthem’s internal appeals process and request that the BDERB grant an expedited review, but must demonstrate that Anthem’s requirement has a “significant adverse economic effect” on the physician. If the BDERB determines that this has not been demonstrated, it will dismiss the claim pending exhaustion of Anthem’s internal appeals process. A copy of the “Request for Dispute of Records Requirement” can be downloaded at www.hmosettlements.com. Q: Are there further appeal rights after the BDERB decision? Is the decision binding?
A: The decision made by the BDERB is final and is binding on both Anthem and the physician or physician group.
Q: What if I have multiple claims for the same situation?
A: A physician or physician group with multiple claims for similar situations can submit those disputes to the BDERB together, if the total of the disputes adds up to more than $500. Note: The filing fee is payable with your first submission.
Q: What if I have disputed amounts of $500 or less?
A: If physician’s billing dispute amounts are $500 or less, additional, similar billing disputes can be submitted within one year of the original billing dispute submission date to accumulate an amount in excess of $500. Note: The filing fee is payable with your first submission.
Q: Do I have to pay the filing fee?
A: Yes, the filing fee is required.
Q: Where do I send my payment for the filing fee?
A: You must submit the filing fee to the BDERB at the same time the billing dispute is submitted.
Q: How will I know that I have exhausted the internal appeals/review process?
A: Please refer to the internal appeals/review policies and procedures at anthem.com to be sure the proper procedures have been followed. If you have followed the proper procedures and received Anthem’s decision, the related notification will state that the internal appeal/review process is exhausted. Also, if you have followed the proper procedures but Anthem failed to notify you of its decision within 30 calendar days after receiving all documentation reasonably needed to complete the internal appeal/review, the internal appeal/review process is deemed to be exhausted.
Q: Who can submit disputes to the BDERB?
A: Physicians who have participated as class members of the Shane-Thomas Managed Care Settlement Agreement and physician groups that consist of such physicians. If you are uncertain whether you are part of the Settlement Class, please contact Anthem’s provider services department at 303-831-2359.
Q: Who should I contact to check the status of my billing dispute submitted to the BDERB?
A: Please contact the BDERB, IMEDECS at 215-855-4633.
Q: Can I fax my request to the BDERB? If so, what is the fax number?
A: Yes, physicians may fax the billing dispute to IMEDECS at 215-855-5318.
Please use the Provider Dispute Resolution Form for all Provider appeal requests. Please send all requests to the appropriate address listed in the Telephone/Address Directory section
Member Non-Compliance Procedure
If a member refuses treatment that an Anthem-network Provider has recommended, the Provider may decide that the member’s refusal compromises the Provider-patient relationship and obstructs the provision of proper medical care. Providers will try to render all necessary and appropriate professional services according to a member’s wishes when the services are consistent with the Provider’s judgment. If a member refuses to follow the recommended treatment or procedure, the member is entitled to see another Provider of the same specialty for a second opinion. The member may also pursue the appeal process. If the second Provider's opinion upholds the first Provider’s opinion and the member still refuses to follow the recommended treatment, Anthem may then terminate the member’s coverage following 30 calendar days’ notice to the member. If coverage is terminated, neither Anthem nor any Provider associated with Anthem will have any further responsibility to provide care to the member.
Anthem may also cancel the coverage of any member who acts in a disruptive manner that prevents the orderly operation of any Provider.
Anthem has established and monitors network adequacy standards to help ensure that our members have adequate, appropriate and timely access to primary care physicians (family and general practitioners, internists and pediatricians who have agreed to act as PCPs), high-volume specialists, hospitals and other health care Providers. These adequacy standards include the number of Providers, the geographic distribution of Providers, and timely access for routine, emergency and urgent care conditions. For information about Anthem’s network access plan, here. Colorado Access and Availability Standards
Accessibility- Plan’s members can obtain available services
| PCP Regular/Routine Care ≤30 days |
| PCP Urgent Care within same day or 1 day |
| PCP After-Hours Care 24 X 7 |
| PCP Open Practice |
| Member Complaints unavailable to get a timely appointment |
| Member Telephone Service |
| | Average Speed of Answer (ASA) |
| | Abandonment Rate |
| Behavioral Health - After hours, 24/7 Emergency Access: |
| | Appropriate instructions given by attendant or recording |
| | After hour availability of a provider for consultation |
| Behavioral Health-Emergency, non-LT within 6 hours |
| Behavioral Health-Urgent within 48 hours |
| Behavioral Health-Routine within 10 working days |
| Behavioral Health Triage |
| | ASA |
| | Abandonment Rate |
Availability- The extent to which the Plan’s practitioners of the appropriate type and number are distributed geographically to meet the needs of its membership
| PCP’s: |
| | 20 PCPs/10,000 members |
| Specialists: |
| | OB/GYN – 2.9 / 10,000 |
| | Ortho – 0.6 / 10,000 |
| | Surgery – 0.7 / 10,000 |
| | Cardiology – 0.5 / 10,000 |
| | Psychiatrists – 2 / 10,000 |
| | Non-MD BH – 8 / 10,000 |
Availability Geographic Distribution
| PCP: |
| | Urban – 2 in 20 miles |
| | Rural – 2 in 60 miles |
| OB-GYN: |
| | Urban – 2 in 45 miles |
| | Rural – 1 in 100 miles |
| Specialist-Medical |
| | Urban - 2 in 45 miles |
| | Rural – 1 in 100 miles |
| Specialist-Behavioral Health (High Volume & Non-high Volume) |
| | Urban – 1 in 10 miles |
| | Rural – 1 in 40 miles |
| Hospitals-Medical |
| | Urban – 1 in 30 miles |
| | Rural – 1 in 60 miles |
| Hospitals-Behavioral Health |
| | Rural – 1 in 45 miles |
| | Urban – 1 in 25 miles |
| Pharmacy |
| | Urban -- 1 in 3 miles |
| | Suburban -- 1 in 5 miles |
| | Rural -- 1 in 15 miles |
Urban or metro is defined as counties having a population of 50,000 or greater.
Member Rights and Responsibilities
Member Rights
Anthem members have the following rights:
| The right to receive information about terms and conditions of their health care benefits |
| The right to be treated respectfully and with consideration |
| The right to receive all the benefits to which they are entitled under the their certificate |
| The right to obtain complete information from a Provider about their diagnosis, treatment and prognosis, in terms they can reasonably understand |
| The right to receive quality health care from Providers in a timely manner and in a medically appropriate setting |
| The right to have a candid discussion with Providers about appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage |
| The right to participate with their physician(s) in decision-making about their health care treatment |
| The right to refuse treatment and be informed by their physician(s) of the medical consequences |
| The right to receive wellness information to help them maintain a healthy lifestyle |
| The right to express concerns and complaints to Anthem about the care and services provided by physicians and other Providers, and to have Anthem investigate and take appropriate action |
| The right to file a complaint or appeal a decision with Anthem as outlined in their certificate and to contact the Division of Insurance about a concern without fear of reprisal |
| The right to expect that their personal health information will be maintained in a confidential manner |
| The right to make recommendations regarding Anthem’s member rights and responsibilities policies |
| The right to receive information about Anthem, its services, the practitioners and Providers delivering care, and their rights and responsibilities as an Anthem member |
Member Responsibilities
Anthem members have the following responsibilities:
| The responsibility to use Providers who will provide or coordinate their total health care needs, and to maintain an ongoing patient-physician relationship |
| The responsibility to provide complete and honest information about their health care status and history |
| The responsibility to follow the treatment plan recommended by member’s Providers |
| The responsibility to understand how to access care in non-emergency and emergency situations, and to know their health care benefits as they relate to out-of-network coverage and copayments |
| The responsibility to notify the Provider or Anthem about concerns they have about the services or medical care they receive. |
| The responsibility to be considerate of the rights of other members, Providers and Anthem’s staff |
| The responsibility to read and understand their certificate and the Health Plan Description Form |
| The responsibility to pay all member payment requirements in a timely manner |
| The responsibility to provide Anthem with complete and accurate information about other health care coverage and/or benefits they may carry |
| The responsibility to participate in understanding their health problems and developing mutually agreed upon treatment goals with their Provider |
Overview and Policy Statement
Anthem members are encouraged to seek resolution of any concern or problem they may have related to Anthem or any of its programs or processes. If a member has an inquiry or complaint, Anthem associates will use available resources to resolve the problem informally when possible. If the member remains dissatisfied with Anthem’s response to the inquiry or complaint, the member may submit an appeal according to the procedures described in the member’s certificate and as set forth in this section. Anthem will investigate the complaint or appeal and notify the member of the resolution of the complaint or appeal in a timely manner. Anthem is also committed to helping members who, due to physical conditions, language barriers or other special needs, may need assistance in exercising their complaint and appeal rights. Anthem will use reasonable methods to accommodate the special needs of these members in accessing the appeals process.
To Initiate a Complaint
If a member has a complaint about any aspect of Anthem’s service or claims processing, the member may 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 or HMO Colorado
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.
To File an Appeal
When Anthem’s actions have resulted in an adverse benefit determination (e.g., a claim for services or a request for preauthorization that was 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 adverse benefit determination. Members may send written appeals to the following address:
| Anthem Blue Cross and Blue Shield or HMO Colorado
Appeals Department
700 Broadway CO0104-0430
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 and other information relevant to the appeal. Anthem will assign an associate to help the member during 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 on the member’s behalf any level of appeal review with Anthem. 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, if a benefit is denied based on utilization review, an independent external review appeal is available to the member. “Utilization review” refers to 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 and retrospective review. Utilization review also includes reviews for 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.
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 or peers, unless the reviewing physician is a clinical peer. A clinical peer is a physician or other health care professional who holds a non-restricted license in a state of the United States and who is in the same or a similar specialty as one who would typically manage the member’s medical condition, procedure or treatment under review.
The member does not have the right to attend the level 1 appeal meeting, but the member is entitled to submit written comments, documents, records and other material related to the request for benefits for the reviewer(s) to consider. 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 comments, documents, records and other information submitted by the member related to the request for services, 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 Anthem’s receipt of the appeal request. Level 1 appeals that do not involve utilization review will be resolved within 30 calendar days (60 calendar days for post-service claims) of Anthem’s receipt of the appeal request. The appeal decision timeframes may be extended if the member requests or voluntarily agrees to an extension.
Voluntary Level 2 Appeal: If the adverse benefit determination is not resolved to the member’s satisfaction under the level 1 appeal process, the member may submit a voluntary level 2 appeal. Upon request, Anthem will provide the member with sufficient information related to the level 2 appeal to enable the member to make an informed judgment about whether to submit the adverse determination for level 2 appeal review. The member’s decision to pursue, or not to pursue, a level 2 appeal will have no effect on the member’s right to any other benefit under the member’s Anthem insurance policy or certificate.
If the member chooses to pursue a level 2 appeal, the member must request the level 2 appeal 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 1) request the opportunity to appear in person or by teleconference before the level 2 appeal panel; 2) prepare in advance for the appeal review and receive from Anthem, upon request, copies of all documents, records and other information that is not confidential or privileged relevant to the member’s request for benefits; 3) present the member’s case to the appeal panel; 4) submit written comments, documents, records and other material related to the request for benefits for the appeal panel to consider when conducting the review both before and, if applicable, at the appeal meeting; 5) if applicable, ask questions of any Anthem representative on the review panel; 6) be assisted or represented at the appeal meeting by an individual of the member’s choice and bring counsel, advocates and health care professionals to the appeal meeting; and 7) 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 include Anthem associates who have appropriate professional expertise. A majority of the panel will include 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 majority of the persons reviewing the appeal will be health care professionals who have appropriate expertise. Such reviewing health care professionals will not have been previously involved in the member’s appeal review process or the member’s care, will not be a member of Anthem’s board of directors, 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. 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 must notify Anthem at least seven days before the meeting.
In conducting the review, the appeal panel will consider all comments, documents, records and other information submitted by the member related to the request for services, regardless of whether that information was submitted or considered in connection with the level 1 appeal decision. Unless the member requests otherwise in connection with a level 2 appeal involving utilization review, Anthem will not allow an audio or video recording of the appeal meeting to be made. After private deliberation, the appeal panel will issue a written decision, which Anthem will provide to the member within seven days of completing the appeal meeting.
Expedited Appeals: A member or a member’s representative (including the member’s health care 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 stays 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 an expedited appeal may be made verbally or 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 meeting, but the member is entitled to submit written comments, documents, records and other material related to the request for benefits for the reviewer(s) to consider. 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 comments, documents, records and other information submitted by the member related to the request for services, regardless of whether that information was submitted or considered in connection with the initial adverse benefit determination. Anthem will make its decision expeditiously, 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 three days will 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 member must make the request to Anthem within 60 calendar days after the date the member receives the 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 the member’s 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 Request for Independent External Review of Carrier’s Final Adverse Determination Form referenced in the paragraph directly above. The independent external review entity will make its determination 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.
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