Cnsumer Guide t Health Insurance Appeals Table f Cntents Intrductin Where t start Step 1: Identify the surce f yur cverage and the issue Where d yu get yur cverage? What kind f denial did yu receive? Is yur medical situatin urgent? Is yur denial intentinal r just a billing errr? What des yur plan cver? Step 2: Preparing t appeal Wh regulates yur health plan s appeals prcess? What d yu d if yu have a bill because f a denial? Hw d yu prepare fr an appeal? Step 3: Appeals prcess Typical steps f an appeal Successful appeals Traits f unsuccessful appeals Why cnsumers lse appeals Step 4: Winning yur appeal Tips fr appeals Tls Cmmunicatins Lg (fillable) Infrmatin Wrksheet (fillable)
Intrductin This guide will help yu understand yur appeal rights if yu get a denial frm yur health insurance cmpany. As a result f federal health care refrm, many f the changes t appeal rights started in mid-2011, althugh insurance cmpanies did nt have t make changes t all plans. Grandfathered plans (thse that existed befre March 23, 2010, and meet ther criteria) are exempt frm the new requirements. Talk with yur health insurance cmpany t find ut hw t appeal when yur plan is grandfathered. Ask yur insurance cmpany if yu need any frms t file yur appeal. Send yur cmpleted appeal letter r frms (if required) directly t the cmpany. Fr help understanding appeals, call ur Insurance Divisin cnsumer htline at 1-888-877-4894 (tllfree). Ask t speak with a Life and Health advcate. C 2
Where t Start Appeals generally have three phases: 1. Denial f request fr service r payment 2. Internal appeal t yur health plan 3. External appeal t an independent reviewer (fr certain denials) T knw what appeals prcess t fllw, answer these questins: What kind f insurance d yu have? D State f Oregn r federal fficials regulate yur plan? Is yur plan a new plan (nn-grandfathered) r an ld plan (grandfathered)? Is yur denial a pre-service issue, meaning yu have nt yet received the services, r a pst-service issue, meaning yu have received the services and may be receiving a bill? If it s a pre-service issue, is it urgent? Urgent means that yur health may suffer if yu d nt receive the service. All insurance cmpanies have avenues t reslve issues withut having t appeal: When in dubt, ask yur health plan t re-evaluate the denial Yur health plan CANNOT drp yur cverage r raise yur rates because yu ask it t recnsider a denial. Yu are allwed t ask fr an appeal it s yur right. Yu d nt have t pay fr the appeal. Yu can ask t cntinue t receive services during the appeal, but if the denial is nt verturned, yu will have t pay fr thse services. Independent review rganizatins ruled in favr f Oregn cnsumers in 34 percent f appeals made frm 2008 thrugh 2010. 3
Step 1: Identify the surce f yur insurance cverage and the issue Where d yu get yur cverage? Cverage surce D yu and yur family have insurance thrugh yur emplyer? D yu have insurance thrugh a public prgram? Examples: Medicare, Oregn Health Plan, Healthy Kids, r anther kind f state r federal prgram. D yu have a plicy that yu r a family member purchased directly frm an insurance cmpany? Type f Plan If yes, then yu have a grup plan If yes, then yu have a gvernment-spnsred plan If yes, then yu have an individual plan Nte: Nt all types f plans are required t prvide an appeal prcess. Yu may have smething ther than a cmprehensive health plicy r a health benefit plan. Fr example, yu might have a lng-term care plicy r a Medicare plicy r disability plicy. Cntact the insurance cmpany f the plicy fr appeals infrmatin. C 4
Step 1: Identify the surce f yur insurance cverage and the issue What kind f denial did yu receive? Chances are yu received a denial frm yur health insurance cmpany fr ne f these reasns: Yur health insurance cmpany: Refused t pay fr medical services r care yu already received. Denied apprval fr treatment r medical services yu are currently receiving r fr treatment yur dctr thinks yu need. If yu have been denied fr an urgent medical need, yu may qualify fr a quicker r expedited appeal. If yu were denied fr anther reasn, call us at 1-888-877-4894 (tll-free) t see if yur situatin qualifies fr an appeal. Is yur medical situatin urgent? If yu have received a denial fr a pre-service and yur dctr believes yur situatin is urgent, yur health insurance cmpany will review yur appeal faster than if it s nt an urgent medical situatin. This is called an expedited appeal. These culd be handled by the insurance cmpany r sent fr an external review by an independent review rganizatin (IRO). IROs are discussed in detail later in this guide. Yu can file an expedited appeal if yu: Are currently receiving r yu were prescribed t receive medical services r treatment; and Have a situatin that is described as urgent by yur dctr. Urgent means yur dctr believes a delay in getting these services: Culd seriusly jepardize yur life r verall health, r yur ability t regain maximum functin. Yu cannt file an expedited appeal if yu: Already received the services r treatment and yur health insurance cmpany denied the claim, r Yur situatin is nt urgent. Wh decides if yur situatin is urgent? Yur dctr r medical prvider will decide if yur situatin is urgent. 5
Step 1: Identify the surce f yur insurance cverage and the issue Hw d yu file an urgent r expedited appeal? Yu r smene yu have authrized t speak fr yu can call yur health insurance cmpany t file an appeal. Yu may file an urgent r expedited appeal verbally r in writing. Yur health plan may respnd with a verbal decisin but must put that decisin in writing within 72 hurs f receiving yur request. If yur appeal qualifies fr review by an independent review rganizatin, yur insurer may nt require that yu cmplete an expedited internal appeal befre beginning an expedited independent review. If yu need t file an urgent r expedited appeal, we suggest yu r smene r yur behalf (including yur medical prvider) immediately call yur health insurance cmpany. Is yur denial intentinal r is it just a billing errr? If yu receive a denied claim, yu shuld first lk t see if it is because f a billing errr. Re-read the paperwrk r materials yur health plan sent. These are called Explanatin f Benefits (EOB) statements. Cnfirm that: Yu (r a cvered dependent) made the visit t the dctr r medical prvider. Make sure the cvered persn, the dctr, and the health insurance cmpany are listed. Check t make sure the dctr r medical prvider billed yur health plan crrectly: Are the charges crrect? Yu may need t cntact yur dctr s billing staff t determine whether the cdes used t bill yur plan match the services yu received. Is the date r dates f service crrect? If any f the details listed abve are nt crrect, r yu aren t sure what smething n yur Explanatin f Benefits means, call yur dctr r medical prvider s billing ffice. Ask yur prvider t send yu an itemized cpy f yur bill. (This is helpful in determining what was and was nt paid fr.) Ask them t explain yur bill. If the billing ffice tells yu everything was billed crrectly and yu believe yur health insurance cmpany shuld have paid the bill, read Billing Errrs fr further infrmatin and instructins. Yu may als call ur Cnsumer Advcacy cnsumer line at 1-888-877-4894 (tll-free). We ll help yu decide if yu need t file a cmplaint with ur ffice, r file an appeal with yur health insurance cmpany, r bth. 6
Step 1: Identify the surce f yur insurance cverage and the issue Keep detailed recrds Befre yu cntact anyne, create a lg t dcument: The type f cntact yu made, including the telephne number The date Wh yu talked t What was said One reasn t keep detailed recrds is that insurance cmpanies may hnr their mistakes. If yu received incrrect infrmatin frm an insurance cmpany s custmer service representative, the cmpany will verify that infrmatin. The cmpany may hnr that mistake, but nly n past denials. It will nt make the same decisins in the future nce it prvides the crrect infrmatin. Billing errrs If yu think a billing errr ccurred, ask yur dctr s ffice fr details abut the Current Prcedural Terminlgy (CPT) r treatment cde. Smetimes valid disputes ccur abut treatment cdes that dctrs and ther medical prviders used t bill the health insurance cmpany. Generally, health insurance exclusins dn t refer t CPT cdes. They refer t specific treatments and diagnses. If a mistake was made, ask custmer service t send yu in writing hw the crrectin will be made. If yu think the cdes dn t fairly represent the treatment yu received, yu can ask yur dctr t re-bill the insurance cmpany using the crrect cde and include yur medical recrds fr that visit. 7
Step 1: Identify the surce f yur insurance cverage and the issue What des yur plan cver? Yur insurance plicy shuld explain: Yur health care benefits and any limits n the number f times yu can use a specific benefit (fr example, sme plans cver nly 10 visits per persn, per year t see a chirpractr). Details abut c-pays that is, cst sharing with yur insurance cmpany (Example: Yu may have a c-pay f $20 each time yu visit the dctr). Remember, fr new (nngrandfathered) health plans, there is n lnger any cst sharing fr preventive services. If yu are unsure if a service qualifies as preventive, call ur cnsumer advcates at 1-888-877-4894 (tll-free). The deductible, if any, that must be met befre the plan will start t pay fr medical care received. The exclusins r limitatins t the plicy. Hw the plicy defines medical necessity and experimental r investigatinal treatment. The benefits that require preauthrizatin (advance permissin) frm yur health plan, and hw t get that apprval. Hw t appeal decisins made by yur health plan. The medical prviders yu can use. Hw the plan pays fr services frm an ut-f-netwrk prvider. Nte: If yu have grup health insurance cverage thrugh an emplyer, it is generally the emplyer s respnsibility t prvide yu a cpy f the plan r tell yu where nline t find plan infrmatin. Befre yu decide t file an appeal, read: Yur cvered benefits in yur plan s benefits bklet. What yur health plan will nt cver. Yu will find this in the exclusins and limitatins sectin. (Fr sme plans, yu may need t cntact yur health plan directly fr this infrmatin.) Infrmatin abut yur benefits Make sure yu have the mst recent cpy f yur plan s benefits bklet, which shuld include the specific exclusins and limitatins t yur plan. 8
Step 2: Preparing t appeal Wh regulates yur appeals prcess? Generally, state r federal laws and regulatins establish yur appeal rights, and fficials frm these gvernments regulate the prcess. Hwever, sme plans are allwed t set their wn rules. Here are guidelines abut wh t cntact t learn mre abut yur appeal rights. Individual: If yu buy an individual insurance plicy (meaning yu dn t get cverage thrugh an emplyer) directly frm a cmpany, the Oregn Insurance Divisin likely regulates the plan and its appeals prcess. Cntact an advcate: 1-888-877-4894 (tll-free). Grup: If yu have grup cverage thrugh an emplyer, ask yur plan administratr r yur human resurces department abut the appeals prcess and wh regulates appeals. It culd be state r federal agencies r a plan that desn t fllw state r federal requirements and is allwed t establish its wn prcess. Yu can als call the Insurance Divisin fr help: 1-888-877-4894 (tll-free). Medicare: If yu have Original Medicare (Parts A and B), a Medicare Advantage Plan, r Medicare prescriptin drug cverage, Medicare is the cntact. Call Medicare at 800-633- 4227 (tll-free) r visit the Medicare Appeals and Grievances website. Yu can als cntact a state prgram that cunsels peple with Medicare, the Senir Health Insurance Benefits Assistance (SHIBA): 800-722-4134 (tll-free) r www.regnshiba.rg. Medicare Supplement plicies (Medigaps): The Oregn Insurance Divisin regulates Medicare Supplement plans. Call: 1-888-877-4894 (tll-free). Oregn Health Plan: Cntact a casewrker. Military persnnel with Tricare: Call 1-253-572-2888 r 1-253-572-2350 r visit www.tricare.mil/cntacts/ What if yu have a dctr bill because f a denial? If yu are appealing the denial f services already received, yu might get a bill frm yur dctr. While awaiting yur appeal decisin, yu can: Ask the medical ffice if yu can delay paying it until yu knw the utcme f yur appeal. Ask the medical ffice t nt send the bill t cllectins; r Set up a payment plan (t avid having the bill sent t cllectins); r Pay the bill and get reimbursed if yu win yur appeal. 9
Step 2: Preparing t appeal Preparing fr yur appeal Use the Appeal Wrksheet t gather infrmatin. Nte: Yur cntact infrmatin (name, mailing address, phne number) Cntact infrmatin fr the persn representing yu, if applicable (such as an attrney, parent r guardian, prvider, r persn wh is acting as yur attrney) Name f the cmpany r grup prviding the health plan Plicy number and, if it applies, claim numbers If yur plan is thrugh yur emplyer, the name and lcatin f yur emplyer Names f dctrs r prviders wh prvided care r wh gave an pinin r recmmendatin Dcuments yu may want t gather t help yu with yur appeal: Yur mst current benefits bklet. All dcuments related t the situatin yu are appealing. Ask what criteria the insurance cmpany used t base its decisin n and t send yu a cpy f that dcument. Yu can share this with yur dctr s the dctr can prvide the infrmatin needed fr the service t be cvered. Any explanatin f treatment r services frm yur medical prvider s ffice. Any denials (als knwn by yur health plan as adverse benefit determinatins). Any research t supprt yur pinin that the denial shuld be verturned (yu can ask yur insurance cmpany custmer r membership services fr the criteria they used as the basis f yur denial). Getting yur dcuments Gather all medical recrds and ther supprting dcuments early n in the appeals prcess. Ask yur dctr t help yu gather the infrmatin yu need. If yu ask the insurance cmpany fr the criteria it used in denying yur claim, yu can give that t yur dctr when yu ask fr help. 10
Step 3: Appeal prcess 1. Yu file yur appeal with yur health plan in writing (yur health plan may prvide a frm). If yu are requesting an expedited appeal due t a clinically urgent situatin, yu may file yur appeal verbally r in writing. 2. Depending n the laws that regulate yur plan, yur decisin culd cme back in 72 hurs if it s urgent, r 30 days therwise. 3. If the decisin is nt reversed n the first appeal, and if yu have yur plan thrugh an emplyer, yur carrier may allw a secnd level f internal appeal. 4. If yu have cmpleted yur internal appeal r appeals and the insurer has nt reversed its decisin, yu may be eligible fr external review. Yu are eligible fr an external review if the decisin denying cverage fr yur service was based n a medical judgment. This final appeal level is a review by an independent reviewer (independent review rganizatin r IRO). An IRO review is a medical file review by a third-party expert, chsen by the Oregn Insurance Divisin, wh is nt affiliated with yur insurance cmpany. 5. If yu decide t file and are granted an external appeal, the IRO assigned t yur appeal: Must ntify yu and yur health plan f a decisin within the timeframe allwed. Must make a decisin that is binding t the health plan. As a last ptin t verturn the denial, yu may pursue legal actin. Currently, all health plans allw at least ne pprtunity t request recnsidering a denial, and sme allw fr mre pprtunities. Successful appeals Appeals are mre likely t g in yur favr if they: Cntain easy-t-prve facts Are t the pint and nly cntain necessary infrmatin Are cmplete Are submitted within the time allwed by yur plan Shw yu were active and persistent in yur interactins with yur health plan and yur dctr Ideas fr appealing different types f denials Medically Unnecessary Have yur dctr (and pssibly ther medical experts) prvide written dcumentatin t explain why the prescribed treatment is medically necessary 11
Step 3: Appeal prcess Experimental Yur health plan may cver treatment ruled as experimental if yu can prve it is ne f the fllwing: Medically necessary The nly treatment that will wrk (dcument what hasn t wrked befre) Less expensive than the standard treatment Cnsidered standard treatment by the medical cmmunity A treatment yur health plan has paid fr in the past fr peple wh have the same medical cnditin as yu Netwrk If yur claim was denied because the dctr was ut f netwrk, yu will have a greater chance t win yur appeal if yu can prve the plan s netwrk had: N prviders with the specialty yu needed Very lng wait times fr the in-netwrk prviders N prviders in yur surrunding area Mistake by yur plan Prve yu r yur medical prvider fllwed the rules under yur health plan. Prve the denied treatment falls within a gray area within the plan s cvered services. If it s nt explicitly excluded, yu culd reasn yur plan shuld pay fr it. If all else fails, smetimes just asking yur health plan fr an exceptin can help yur case! 12
Step 3: Appeal prcess Cmmn traits f unsuccessful appeals Appeals are less likely t g in yur favr if they are: Hard t read Excessively lng and include unnecessary details Highly emtinal and include feelings f frustratin, pain, r anger rather than facts Incmplete Are written with hard-t-read handwriting Submitted past the deadline Why cnsumers lse appeals Missing infrmatin Yu dn t have a letter frm yur dctr detailing why a prcedure is medically necessary. Yur letter t the health plan desn t address yur specific medical issues r the plan s language. Yu didn t prvide dcumentatin f treatments yu tried befre the treatment yur dctr is currently prescribing. Yu didn t prvide infrmatin abut smething the health plan cnsiders relevant and wants t investigate. Yu didn t include evidence shwing hw the medical cmmunity cnsiders yur treatment as standard practice. Nt in the cntract Yu were prescribed r received treatment, r a prescriptin, that s specifically nt cvered by the plan. Yu didn t pay yur premium n time and yur plicy was canceled. The health plan will nt pay fr any medical services after yur plicy was canceled. Yu disputed the cntracted amunt the health plan paid t yur prvider. Yu cannt ask the plan t pay mre r less t a prvider than its cntract allws. Yu asked abut a hypthetical situatin. Unless yur dctr r ther prvider is required t get prir authrizatin fr a treatment he r she determines t be medically necessary, the health plan isn t required t tell yu hw it wuld prcess a claim in advance. Things at the discretin f the carrier, such as a request that a prescriptin be recategrized s that it csts less. 13
Step 3: Appeal prcess Yur dctr s billing ffice makes mistakes. Yur health plan can respnd nly t infrmatin prvided by yur dctr. If yur dctr used the wrng CPT cde, r didn t get prir authrizatin, as the plan requires, then yur health plan desn t have t pay yur claim. Yur prvider may be respnsible fr his r her mistakes. Emplyer and emplyee issues Eligibility Fr example, when an emplyer tells the grup health plan prvider that a wrker n lnger qualifies fr cverage as f a certain date, and the health plan denied any claims that came in fr that wrker after that effective date. Late premium payment When an emplyer fails t pay its prtin f the premium t the health plan and the health plan cancels cverage fr all the emplyees n the plan. Yu cannt fix these last tw issues by filing an appeal. Yu can file a cmplaint with the U.S. Department f Labr. United States Department f Labr - Emplyee Benefits Security Administratin. Phne: 1-866-444-3272 (tll-free). 14
Step 4: Winning yur appeal Tips fr appeals When yu think yur health plan shuld pay fr cverage appeal! Keep detailed medical recrds. Mst appeals require yu t prve smething, and it can be a lt easier t d that if yu have gd recrds. Dcument everything. Stick t the facts and emphasize bjective medical infrmatin ver discussing yur emtins. If smene tld yu he r she wuld get back t yu by a certain day and didn t, call that persn. If smething is nt clear t yu, ask questins until yu understand it. When yu need t send dcuments t yur prvider r yur health plan: Send cpies instead f the riginals. Send dcuments as certified mail, s yu will knw when they are delivered. (Certified mail means smene has t sign fr it, and yu can see wh signed fr it and when.) Yur prtin f the cst f medical care is usually negtiable. Ask yur health care prvider t accept the amunt yur health plan will pay fr a prcedure as full payment. If a health plan wn t pay at all, try t agree n a price fr yu t pay ut f pcket. Ask yur medical prvider t change yur prescriptin if it s nt cvered by yur plan. Fr a denied claim Rule ut the pssibility f a billing errr. Call yur medical prvider's billing ffice first (dcument the call n yur recrds lg). Tell them yu received ntice f a denied payment in the mail frm yur health plan. Ask why yur health plan denied payment fr a visit t their ffice. Yu will be tld it is either a billing errr r a claims prcessing errr - bth f which shuld be cleared up by yur prvider s ffice. If it s nt a billing r prcessing errr, yu will need t appeal in rder t verturn the denial. Make sure yu have a cpy f the current plan summary and exclusins and limitatins. Yu may need t call yur health plan t find ut where yu can find this infrmatin n the plan s website, r ask t have it mailed t yu. 15
Step 4: Winning yur appeal Read the denial t learn: The specific reasn fr the denial The plan prvisin that supprts the decisin What the plan needs t reverse its initial ruling What yur plan s appeals and grievance prcess is and the deadlines Where t send a frmal appeal Cnsider filing a cmplaint with the Oregn Insurance Divisin Call ur cnsumer htline at 1-888-877-4894 (tll-free). Discuss yur case with an insurance advcate. Ask fr a cpy f everything yur plan used fr the denial. Search fr any missing infrmatin in yur file that supprts paying the benefit. Ensure any clinical research yu use is current. Ask yur dctr fr guidance. D yur wn research at www.pubmed.gv. Stay in cntact with yur medical prvider If yu re appealing the denial, tell yur health care prvider's billing ffice staff. Ask them t nt send yur bill t cllectins. If they require payment, yu can: Delay paying it if yur prvider wn t send yu t cllectins; Pay it in full; r Set up a payment plan. Yu will be reimbursed if yu win yur appeal by yur health plan. If yu need a letter frm the medical prvider, cnfirm that he r she will be available t write it (and nt away frm the ffice). Prvide yur medical prvider with a cpy f the cntract prvisin the health plan is using fr the denial. Yu shuld als give yur medical prvider any letters r mems the cmpany sent yu fr denying the claim. This helps him r her fcus their statements n issues related t yur appeal. If time allws, ask t prfread the letter yur dctr writes n yur behalf. Make sure the letter addresses the reasns yur health plan is denying the claim. Sme letters aren t specific enugh r smetimes cntain errrs. Successful appeals have persuasive letters frm dctrs. 16
Step 4: Winning yur appeal Gather all medical recrds and ther supprting dcuments as early in the prcess as yu can. If yur appeal mves n t the external appeal level, yu will want t have everything in yur pssessin. That stage f the appeal prcess has a shrter turnarund time fr a decisin. Yu want the IRO (independent review rganizatin) t have everything it needs in the first few days after yu file the appeal. If yur health plan requests mre time t cnsider yur claim, yu dn t have t grant it. If yur health plan desn t return a final decisin t yu in the time allwed, yu can mve n t the next level f appeal. Fr canceled r rescinded cverage Insurance plans must prvide yu with written ntice at least 30 calendar days befre they can rescind yur health cverage. Nte: A health plan is allwed t rescind a plicy nly fr fraud r intentinal misrepresentatin (such as knwingly mitting a health cnditin n an individual applicatin). Failure t pay premiums Avid making late premium payments. If yu fail t pay yur insurance premiums, yur health plan might grant yu a ne-time exceptin if yur payment is late, but this is nt required. Be aware the cmpany typically will nt allw a secnd late payment and will cancel yur plicy. Canceled COBRA Yur emplyer can cancel yur COBRA cverage if yu dn t make yur premium payments. Federal COBRA law desn t require yur emplyer t ntify yu that it has canceled yur cverage. Hwever, the federal HIPAA law des require a Certificate f Creditable Cverage be issued t the subscriber when cverage has ended. If yu think a frmer emplyer canceled yur COBRA cverage in errr, cntact the U.S. Department f Labr (DOL): 1-866-444-3272 (tll-free). Fr individual health plans The Standard Health Questinnaire is a questinnaire used by insurance cmpanies t determine if they will insure adult applicants based n their health. If an insurance cmpany refuses t sell yu a plicy because yur health histry did nt meet the cmpany s guidelines: Yu can appeal the applicatin denial. Yur applicatin denial fr an individual health plan is nly allwed ne level f internal appeal t make its decisin. 17
Tls Click here fr a fillable Cmmunicatins Lg Click here fr a fillable Infrmatin Wrksheet 18
Cmmunicatin Lg It is imprtant t keep a written recrd f every letter, phne call, email, and cnversatin abut yur appeal. Try t write dwn each cntact right away, while the details are fresh. EXAMPLE Date Cntact type Frm T Summary 3/4/2011 Letter AETNA Me Claim fr my MRI Denied 3/7/2011 (10 AM) Phne call Me 3/08/2011 Phne call Me Dr. Wilsn s ffice. Spke with Carl T. Aetna. Spke with Ruth Jhnsn Date Cntact type Frm T Summary Called t ask if claim was billed prperly. It was. Tld Dr. I want t appeal the denied payment. I asked hw lng I wuld have t file an appeal. Was tld 180 days frm the date f riginal denial (3/1). 440-2970 (9/11/COM)
Appeal Wrksheet Infrmatin abut yur plan: 1. Type: Individual Grup Other 2. Insurance prvider name: 3. Plicy n. (if applicable): Grup n. (if applicable): ID n.: New plan (nngrandfathered) Old plan (grandfathered) 4. Wh regulates it? 5. Cverage still effective Cverage terminated If terminated, date f terminatin: 6. Type f health plan: HMO PPO Traditinal indemnity (fee-fr-service plan) 7. Based n the infrmatin abve, can yu see ut-f-netwrk prviders? Yes N If yes, hw much is the c-insurance, c-pay r deductible? 8. Wuld yu need a referral frm a primary-care prvider fr a specialist? Yes N If yes, are there restrictins t which specialists yu can see (e.g., in-netwrk vs. ut-f-netwrk)? Yes N If yes, restrictins are: Infrmatin abut yur denial: 1. Pre-service claim Pst-service claim If it is pre-service, is it urgent? Yes N 2. Date f the denial: Hw lng d yu have frm this date t appeal? 3. Claim n.: Diagnstic cde (if knwn): 4. Treatment r service that needs t be cvered: 5. D yu have evidence t prve that it shuld be cvered? Yes N (e.g., page # f EOC, dctr s recmmendatin ntes, ntes dcumenting prir health histry) Research that shws hw treatment is necessary r cst-effective in the lng run? Yes N 6. Cntact infrmatin fr the recipient f the appeal and key dates fr the varius stages f the appeal: (e.g. list dates when ne shuld expect a respnse frm cmpany). 7. Is yur issue ne that is listed in the exclusins and limitatins (Evidence f Cverage) that the health plan will nt cver? Yes N Medical prvider infrmatin: Medical prvider s name: Prvider s service/treatment address: Prvider s phne number: 440-2971 (9/11/COM)