If a participant or provider believes that Acentra incorrectly denied all or part of a medical service, he may initiate the appeals process. The attending provider may contact Acentra to discuss any findings of "not medically necessary" with the physician who initially made the determination. If the physician is not available, another physician will be made available. Based on that discussion, the Acentra staff physician will determine whether the original decision should be affirmed or amended. The enrollee and attending physician will be notified in writing of the results of this review.
When an initial determination not to certify a health care service is made prior to or during an ongoing service requiring review, and the attending physician believes that the determination warrants immediate appeal, the attending physician shall have an opportunity to appeal that determination over the telephone on an expedited basis, within one working day.
The attending provider or participant may submit a request for appeal, outlining the reason for the request, within 180 days of the initial denial decision. A thorough review and discussion of medical records and other supporting documentation will be undertaken by a specialist with experience in the condition or procedure requested. Based on this review, a decision affirming or amending the original decision will be rendered and provided in writing to the enrollee and the attending provider. The provider may also request an expedited internal appeal at the same time as an expedited external review if the provider believes that the patient's life could be in jeopardy waiting the timeframe to complete a standard internal appeal.
Within four months after the date of receipt of an adverse determination or 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 necessity, appropriateness, health care setting, level of care or effectiveness. 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 Acentra. 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 in accordance with the procedures above will result in the participant's right to an appeal and rights to sue being forfeited.