Appeals for noncoverage

All coverage determinations that result in a denial, reduction in coverage request, or a failure to provide or make payment (in part or in whole) for a benefit, contain instructions for a member appeal. Members may contact Member Services for more information.

You may request a standard appeal on the member’s behalf when the member has signed the appropriate authorization of representative form.

If you are the treating provider, you may request an expedited appeal (72 hour completion) without member permission when the standard appeal timelines (7 to 60 days) meet one of the following criteria:

  • Could seriously jeopardize the life or health of the member
  • Could seriously jeopardize the ability of the member to regain maximum function
  • Delay would subject the member to severe pain that could not be adequately managed without the care or treatment

If you submit an expedited request, please include medical records to support your appeal and provide a valid phone number should we need to contact you for any reason.

Content on this page is from the provider manual | Disclaimer