APPEAL GRIEVANCE PROCESS

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					APPEAL / GRIEVANCE PROCESS

HOW TO OBTAIN INFORMATION ABOUT THE APPEAL PROCESS:

The Appeal/Grievance process is available to the member, the member's duly
authorized representative, the provider of record, or the provider of record's duly
authorized representative. Questions may be posed about issues concerning the health
benefit plan, including benefit determinations and care provided. Providers may contact
AB following an adverse determination for a peer consultation on the decision. Since
most questions can be resolved informally, the first step in the Appeal/Grievance
Process is to contact an Anthem Behavioral Member Services Representative at 800-
424-4014 for additional information.


PROVIDER APPEALS
Policy Statement
The Provider appeals process is available for administrative and payment issues only.
Members may appeal utilization review decisions in accordance with the member
appeals process. Many administrative issues may be resolved more quickly by calling
Customer Service (see Attachment F) or by submitting a Provider Adjustment Request
Form (see Attachment H). Please do not use the Provider Adjustment Request Form to
file an appeal request.

All Provider appeal requests must be submitted in writing to the Anthem Behavioral
Provider Appeals Department. Providers have 180 calendar days from the date of the
Explanation of Payment (EOP) or from the date of the reconsideration denial to appeal
a claims adjudication action. This policy does not apply to routine Provider inquiries that
AB resolves in a timely fashion through existing informal processes, i.e., through
Customer Service or by submitting a Provider Adjustment Request Form. AB will make
a determination about the Provider dispute resolution request within 60 calendar days
of receipt of all the necessary information. When AB does not receive all the necessary
information to make a decision, AB will request, in writing within 30 calendar days of
receipt of the Provider dispute resolution request, that the Provider submit the additional
information needed in writing. AB will allow 30 calendar days from the date that AB
requests the additional information for the Provider to submit the required information.
Upon receipt of the additional information, providing it is received within the 30-
calendar-day timeframe, AB will complete the appeal process within 60 calendar days.
If the Provider does not respond within the 30-day timeframe, AB will close the appeal
request without further review. Further consideration of the closed Provider appeal
request must begin with the Provider submitting a new appeal request in writing. This
policy complies with C.C.R. 4-2-23.

The above Provider appeals policy is summarized as follows:
•   When all the necessary information is submitted with a Provider appeal request, AB
    will send written confirmation of receipt within 30 calendar days of receipt of the
    appeal request. When the appeal request is resolved in favor of the Provider within
    30 calendar days in accordance with this policy, the notice of favorable resolution
    will act as written confirmation.

•   When AB does not receive all the necessary information to make a decision, AB will
    send a written notice to the Provider within 30 calendar days of receipt of the appeal
    request, indicating the information that is required.


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•   When the Provider does not submit the additional information required by AB and
    AB closes the appeal request, AB will notify the Provider that the case is closed and
    that further consideration of the closed appeal request must begin with the Provider
    submitting a new appeal request in writing.

Designated Provider Representative and Face-to-face Opportunity
AB offers Providers the opportunity to designate a Provider representative in the appeal
process. AB will allow the Provider or the Provider’s representative the opportunity to
present in person the Provider’s rationale for the appeal request. If the Provider
determines that a face-to-face meeting is not practical, AB will offer the Provider the
opportunity to utilize alternative methods, such as a teleconference, to present the
Provider’s rationale for the appeal request. AB may require appropriate confidentiality
agreements from a Provider representative as a condition of participating in the appeal
process. The parties may mutually agree in writing to extend the timeframe beyond the
60 calendar days established by this policy for receipt of all the necessary information.

AB will provide notification of the determination to the Provider. If the determination is
not in the Provider’s favor, written notification will include the principal reasons for the
determination.

According to the issue involved, AB’s Appeals Team, Medical Directors, Medical
Review, Medical Policy and Provider Contracting Departments, and/or other appropriate
business areas may review appeal requests.

Please send Provider appeals requests, in writing, to the Provider appeals address:

                                Anthem Behavioral Health
                                Appeals Department-West Region
                                7600 E. Eastman Avenue
                                Tamarac Plaza III, Suite 500
                                Denver CO 80231


MEMBER NON-COMPLIANCE PROCEDURE
If a member refuses treatment that an AB 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, then Anthem has the
option to terminate the member’s coverage following a 30-calendar-day 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 elect to cancel the coverage of any member who acts in a disruptive
manner that prevents the orderly operation of any Provider.




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MEMBER APPEALS
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. Anthem believes that
an effective complaint and appeals process helps members and Anthem receive a fair
and objective forum. If a member has an inquiry or complaint, AB staff will use all
available resources to resolve the problem informally. If the member remains
dissatisfied with AB’s response to the inquiry or complaint, the member may submit an
appeal according to the procedures described in the member’s Certificate. AB will fairly
and adequately investigate all complaints and appeals and notify the member of the
resolution of the complaint or appeal in a timely manner. Anthem is also committed to
assisting members with physical health, language and/or other impediments in
exercising their complaint and appeal rights. AB will use reasonable methods to
accommodate the special needs of these members in accessing the appeals process.
To help ensure that member appeals receive unbiased reviews, members are offered
two levels of review. If a benefit is denied based on utilization review, an independent
external review appeal is also available to the member. The member’s appeal must be
in writing (except for expedited utilization review appeals).

This section explains what to do if a member disagrees with AB’s denial, in whole or in
part, of a claim, requested service or supply, and it includes instructions on initiating a
complaint, filing an appeal or filing a grievance with AB. 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 in the following Appeals
section.

Appeals
While AB encourages members to file appeals within 60 calendar days of the adverse
benefit determination, AB must receive the member’s written appeal within 180
calendar days of the adverse benefit determination. Appeals may be filed for pre-
service or post-service denials. Pre-service and post-service appeals will be handled in
the same manner, except where noted in this policy. Members are notified at all levels
in the appeal process that they have the right to submit written comments, documents,
records or other information relevant to their appeal, as well as their right to appoint a
representative to act on their behalf. AB will assign a customer advocate to assist the
member in the appeal process. Members may send written appeals to the following
address:

                               Anthem Behavioral Health
                               Appeals Department-West Region
                               7600 E. Eastman Avenue
                               Tamarac Plaza III, Suite 500
                               Denver CO 80231

An appeal may be filed with or without first submitting a complaint. 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 should include
any documents not originally submitted with the claim or request for the service or
supply and any information that may have a bearing on Anthem’s decision. For a
thorough, unbiased review, the member may access two internal levels of appeal. In the
case of a benefit denial based on utilization review, an independent external review
appeal is also available to the member. Members may designate a representative (e.g.,
the member’s physician or anyone else of the member's choosing) to file any level of

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appeal review with Anthem on the member’s behalf. 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.

Level 1 Appeal: During the first level of appeal, AB 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. The person(s) appointed to review a Level 1 appeal involving
utilization review will consult with an appropriate clinical person or persons in the same
specialty as someone who would typically manage the case being reviewed. The
consulting clinical person will not have been involved in any prior review of the case.
For pre-service and post-service utilization review issues, the member will receive a
response to the member’s Level 1 appeal within 20 business days (or no later than 30
calendar days) of receipt of the appeal request. Non-utilization review pre-service
appeals will typically be resolved within 30 calendar days. Non-utilization review post-
service appeals will be resolved in 60 calendar days. The appeal decision timeframes
may be extended if the member requests or voluntarily agrees to the extension.

Level 2 Appeal: This is an appeal of an adverse benefit determination that has not
been resolved to the member’s satisfaction under the Level 1 appeal process. The
Level 2 appeal must be requested within 60 calendar days after the member receives
AB’s adverse determination of the Level 1 appeal. The member may appear at or be
teleconferenced into a hearing concerning the appeal to present testimony, introduce
documentation the member believes supports the member’s appeal and provide
documentation requested by Anthem. The panel of reviewers will include a minimum of
three people and may be composed of Anthem associates who have appropriate
professional expertise. A majority of the panel will be comprised of 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 meet the following
criteria:

   •   They have not been involved in the care previously.
   •   They are not members of Anthem’s board of directors.
   •   They have not been previously involved in the member’s appeal review process.
   •   They do not have a direct financial interest in the case or in the outcome of the
       review.

Anthem will issue a copy of the written decision to the member and to the Provider who
submits an appeal on the member’s behalf, if any, within 50 business days of receipt of
the Level 2 appeal request by Anthem’s Appeals Department.

Expedited Appeals: A member or a member’s representative (including the member’s
practitioner) has the right to request an expedited review if handling the appeal as a
standard 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 their existing ability to live independently.
Expedited review is granted to all requests concerning admissions, continued stay or
other health care services for a member who has received emergency services but who
has not been discharged from a facility. The decision will be made, and the member or
representative will be notified, within 72 hours of the request.



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An appropriate clinical peer or peers not involved in the initial denial will evaluate
expedited appeals. The customer advocate will work with AB’s Medical Director to
determine the appropriate specialty and/or specialist to review the expedited appeal.
The expedited appeal will be delivered to the external specialist for review, and the
external reviewer will call, write or e-mail AB with the reviewer’s recommendation. The
recommendation is then reviewed by AB’s Medical Director, who makes a
recommendation based on the external review by a specialist in the appropriate field of
medicine. The customer advocate will notify the member and the member’s Provider via
phone or e-mail and follow up in writing regarding the determination of the expedited
appeal.

AB will not provide an expedited review for retrospective denials.

Independent External Review Appeals: Independent external review appeals are
conducted by independent external review entities, which are selected by the Colorado
Division of Insurance. An independent external review appeal is available only when a
claim or requested service or supply was denied based on utilization review and when
the denial has gone through Anthem’s Level 2 appeal process. Members will be
informed of the right to appeal to an independent external review entity in the
notification that the Level 2 appeal was upheld. The notification will include clear
instructions for accessing the independent external review. In addition, Anthem will
notify members at least annually about the availability of external appeals. The
notification will be in the form of newsletters or member handbooks sent to all members.
The notification will describe the availability of external appeals.

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 (see the Telephone/Address
Directory section for phone numbers). The request must be made to Anthem within 60
calendar days after the date of receipt of notice of Anthem’s Level 2 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 a 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 form referenced in the
paragraph above. Determinations will be made by the independent external review
entity 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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Complaints
If a member has a complaint about any aspect of AB’s clinical care or services, the
member should contact AB’s Customer Service Department. A trained Customer
Service representative will work to resolve the member’s concerns. A member may also
submit a written complaint to the following address:

                               Anthem Behavioral Health
                               Quality Management Department
                               7600 E. Eastman Avenue
                               Tamarac Plaza III, Suite 500
                               Denver CO 80231


Grievances
A grievance is a complaint about the quality of care or service a member receives
from a Provider or facility contracted with AB.

A member may send a written grievance to the following address:

                       Anthem Behavioral Health
                       Quality Management Department
                       7600 E. Eastman Avenue
                       Tamarac Plaza III, Suite 500
                       Denver CO 80231

AB’s Quality Management Department will acknowledge receipt of and investigate the
member’s grievance. AB treats each grievance investigation in a strictly confidential
manner, and findings are not shared with the member unless permission is given by the
practitioner/provider.




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