Provider Appeals and Billing Disputes
Provider Complaint and Appeals Process (also known as the Grievance Process)
You may ask questions about a Covered Individual’s Health Benefit Plan. Since most questions can be handled informally, call the Provider Call Center at 1-800-922-3242 (network/participating provider) or the telephone number on the Covered Individual’s member ID card.
You can request an Appeal if you do not agree with an adverse coverage decision. You may request an Appeal on your own behalf or on behalf of a Covered Individual. If you request an Appeal on behalf of a Covered Individual, written consent from the Covered Individual is required except when an expedited review is necessary. You will be deemed the authorized representative of the Covered Individual and written consent will not be required for an expedited review.
A one level internal Appeal process is available. You can request an Appeal orally, electronically or in writing within 180 calendar days from the date you receive notification of an adverse decision.
Call Member Services at the telephone number on the Covered Individual’s member ID card.
Send your written request to:
Grievances and Appeals
P.O. Box 1038
North Haven CT 06473-4201
If your Appeal is related to a mental health or substance abuse disorder, send your written request to:
Grievances and Appeals
P.O. Box 2100
North Haven CT 06473
Generally, we will respond to your Appeal within 30 calendar days from the date we receive the request.
An expedited Appeal is available if services have not been provided and the timeframe of a standard Appeal review could:
| Seriously jeopardize the Covered Individual’s life or health; |
| Jeopardize the Covered Individual’s ability to regain maximum function; or |
| In the opinion of a health care professional with knowledge of your medical condition, would subject the Covered Individual to severe pain that cannot be adequately managed without the health care service or treatment being requested. |
We will respond to qualifying expedited Appeals within 72 hours of receiving the request except in certain circumstances as outlined below.
Mental Health Disorder and Substance Use Disorder
An expedited Appeal is also available for:
| Substance use disorder or co-occurring mental health disorder; or|
| Inpatient services, partial hospitalization, residential treatment, or intensive outpatient services needed to keep a Covered Individual from requiring an inpatient setting in connection with a mental health disorder. |
We will respond within 24 hours of receiving this type of expedited appeal.
Upon request, you may obtain a copy of the guideline, protocol or other similar criterion on which an appeal decision was based.
Submitting an Appeal Request
In order to ensure a timely and appropriate resolution of an Appeal, it is important that you do not include with your request for an Appeal other issues such as:
| Claims corrections;|
| Claims issues where the Plan has requested additional information;|
| Accounts receivable inquiries; and |
| Request to trace a check. |
We further suggest that you:
| Include the word Appeal in bold in your request;|
| Include, if available, the Covered Individual’s name, ID number, date(s) of service, claim number(s) and the health Plan’s case number;|
| Provide the specific reason(s) for the Appeal (it is important for you to explain to the health plan for each claim exactly why you feel your claim(s) should be reconsidered. Giving a generic reason for the Appeal will make it difficult for us to respond timely and appropriately; and|
| Include all relevant information, such as medical records or other supporting documentation, regardless of whether it was considered at the time the initial decision was made. |
Covered Individual Rights
If the Covered Individual’s Health Benefit Plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA), and the Covered Individual has exhausted all mandatory Appeal rights, the Covered Individual has the right to bring a civil action in federal court under section 502(a)(1)(B) of ERISA.
The Covered Individual can ask us for copies of the specific rule, guideline, protocol or
other similar criterion on which a decision was based. A Covered Individual can also ask us for reasonable access to and copies of all documents, records, communications and other information and evidence relied upon to make a decision. All this information will be provided upon request and free of charge.
If an adverse determination is based on a medical necessity, or experimental treatment, or other similar exclusion or limit, an explanation of the scientific or clinical judgment for the determination applying the terms of the Plan to the Covered Individual’s medical circumstances will be provided free of charge upon request.
If a consultant’s advice was obtained in connection with a Covered Individual’s adverse determination, without regard to whether the advice was relied upon in making the benefit determination, the consultant will be identified upon request.
Fully-insured Plan’s issued in the State of Connecticut and State of Connecticut Employees
After completion of the Appeals process for an adverse utilization review determination or an adverse non-utilization review determination based on Medical Necessity, a Covered Individual, the provider or the duly authorized representative of the Covered Individual or provider will receive information (including the application) regarding an external appeal process administered by the Insurance Department. The Covered Individual must first exhaust all of the utilization review company’s internal appeal mechanisms UNLESS it is determined that the time frame for completion of an expedited internal appeal may cause or exacerbate an emergency or life threatening situation. In an emergency or life threatening situation, the Covered Individual, or provider acting on behalf of the Covered Individual with the Covered Individual’s consent, would not need to exhaust all internal appeals in this situation in order to file for an external appeal. The expedited appeal application must be filed with the Insurance Department immediately following receipt of the utilization review company’s initial adverse determination or at any level of adverse appeal determination. If the expedited external appeal is not accepted on an expedited basis, and the Covered Individual has not previously exhausted all internal appeals, the Covered Individual may resume the internal appeal process until all internal appeals are exhausted and then may file for a standard external appeal within 120 days following receipt of the final denial letter
The Covered Individual, the provider, or the duly authorized representative of the Covered Individual or provider may, at any time, seek further review of an adverse determination by writing to the Insurance Commissioner at State of Connecticut, Insurance Department, Consumer Affairs, P.O. Box 816, Hartford, Connecticut 06142, or by calling (860) 297-3910.
Covered Individual’s enrolled in a self-funded Plan
Covered Individual’s enrolled in a self-funded Plan may have external review rights available.