A participant has the right to appeal any decision that denies payment of a claim or a request for coverage of a health care service or treatment.
If a participant believes that BCBSMS incorrectly denied all or part of a claim, he has the right to obtain a full and fair review. A request for a review must be made in writing to BCBSMS.
The participant has 180 days to request a review after receiving notice of denial from BCBSMS. The participant may provide additional information that relates to the denied claim. If the participant fails to request a review within this timeframe, the right to review is forfeited.
After the claim has been reviewed, if benefits are again denied, the decision will be sent to the participant in writing. The letter will include the reason(s) why benefits are denied, with reference to the Plan provisions on which the decision is based.
If, after following the appeal procedure described above, the participant still disagrees with the determination, a final internal appeal may be submitted in writing to the Department of Finance and Administration, Office of Insurance within 180 days after receiving the second denial from BCBSMS. The request to the Office of Insurance must include a copy of the BCBSMS review decision and all information pertinent to the claim.
The decision of the State Insurance Administrator with the Department of Finance and Administration, Office of Insurance is final and concludes all internal levels of appeal.
Within four months after the date of receipt of a final internal denial of a claim, the participant may file a request for an external review. An external review is available when the final denial involves an issue of medical judgement (including, but not limited to, medical necessity, appropriateness, health care setting, level of care, effectiveness, or whether a treatment is experimental or investigational), or rescission. The participant will be required to authorize the release of any medical records that may be required to be reviewed for the purpose of reaching a decision on the external review. The request must be made through the Office of Insurance and must include all information pertinent to the denied claim. An external review decision is binding on the participant except to the extent the participant has other remedies available under applicable federal or State law.
Failure to request a review within the above referenced time frames and in accordance with the procedures will result in the participant's right to an appeal and rights to sue being forfeited. Note: A participant may request an External Review during any part of the Appeal Process.