Appeals & Complaints
Questions About Your Coverage
For questions about coverage, start by calling your healthplan at the number on your ID card. A representative will try to answer your coverage questions, excluding requests concerning medical necessity review decisions.
Who May File an Appeal?
A patient, or a person authorized to act on their behalf, has the right to request an appeal if they do not agree with MedCom’s decision about the non-certification of treatment, procedures, or services based on medical necessity or determination of experimental or investigational. If the person acting on behalf of the patient is not their legal guardian, an “Authorized Representative Designation” form may be requested by contacting MedCom Care Management at (866) 978-2029.
How to Appeal
The specific appeal process that applies to you is determined by your benefit plan and follows state and/or federal rules that apply to that benefit plan. To appeal a claim for medical necessity, a patient may do one of the following:
The appeal request should include the name of the employee, the employee’s personal identification number (PID), the group name or identification number, all facts and theories supporting the claim for benefits, a statement in clear and concise terms of the reason(s) for disagreement with the handling of the claim and any material or information which indicates the patient is entitled to benefits under the plan. Decisions will be based upon the health benefit plan and requests will be reviewed by someone who was not involved in the initial decision. If the situation involves urgent care, the review and response will be expedited.