Claim Appeal Process

Appealing Claim Determinations

Under the State Employees Group Insurance Program there are formal procedures for you to follow inorder to file an appeal of a Claim determination. The Plan Administrator's internal appeal process must be followed through all available levels. A Plan Participant who believes an error has been made in the benefit amount allowed or disallowed must follow appeal procedures outlined below.

Appeal Process for Managed Care Health Plans

The Department of Central Management Services (Department) does not have the authority to review or process managed care health plan appeals. Managed care health plans must comply with the Managed Care Reform and Patient Rights Act. In order to file a formal appeal, refer to the process outlined in the managed care health plan's Summary Plan Document (SPD) or Certificate of Coverage. Specific timetables and procedures apply. Plan Participants may call the customer service number listed on their Identification Card to request a copy of such documents.

Appeal Process for Quality Care Health Plan (QCHP) and Self-funded Managed Care Plans

There are two separate categories of appeals: medical and administrative. Medical appeals pertain to denials determined by the Plan Administrator to be based on lack of Medical Necessity. Administrative appeals pertain to denials based on Plan design and/or Plan Exclusions and Limitations. The Plan Administrator determines the category of appeal.

The Plan Administrator's internal review process must be used to the fullest extent prior to filing an appeal with the Department. The Plan Participant will receive written notification regarding their appeal rights from the Plan Administrator.

Appeal Information

1. Initial Appeal to the Plan Administrator

Appeals must be initiated with the appropriate Plan Administrator within 180 days of the denial of the initial claim determination. The Plan Administrator will be able to provide more information regarding the denial. In some cases, additional information such as an operative report or x-ray may be required to determine if additional benefits are available. In some cases, a special review by a Physician or dentist may be warranted. Each case will be review and considered on its own merits.

2. Appeal of the Plan Administrator's Decision to DCMS Group Insurance Division

If, after exhausting every available level of review by the Plan Administrator, the Plan Participant still feels that the denial by the Plan Administrator is not in accordance with the published benefit coverage, the Plan Participant may exercise the following procedures for both Medical Necessity and administrative appeals.

For an appeal to be considered by DCMS Group Insurance Division, the Plan Participant must appeal the Plan Administrator's denial in writing within 60 days of the Plan Administrator's written notification.

Submit Appeal Documentation to:

DCMS Group Insurance Division
201 E. Madison Street, Suite 1C
PO Box 19208
Springfield, IL 62794-9208

The Group Insurance Division will determine if the Plan Administrator has appropriately followed the Medical Necessity and/or Plan guidelines.

Medical Necessity appeals must be accompanied by all documentation supporting the reconsideration of the benefit determination.
Administrative appeals are based on Plan Exclusions and Limitations and Plan design. For Administrative appeals, the DCMS Group Insurance Division's final determination is final and binding on all parties.

3. For Medical Necessity Appeals only; Final Review by DCMS Appeal Committee

If the Plan Participant is not in agreement with the decision made by the Department, with respect to Medical Necessity, the Plan Participant may initiate one additional step of the appeal process. An appeal committee appointed by the Director will review whether the Plan Administrator has appropriately followed the Medical Necessity determination procedure and all Plan guidelines.

The Plan Participant must submit a written request to the appeal committee within 60 days of the final determination by the Department.
The appeal committee will review the documentation presented in the appeal to the Department.
The appeal committee will consider the merits of each individual case. If new information is presented during the final determination, the appeal will be returned to the Department for further review and reconsideration.
A bargaining unit Employee covered under AFSCME has the option to request or decline that a designated union representative be a member of the committee. AFSCME shall provide the Department with prior notification, if applicable, of the representative who will serve as a member of the committee.
Plan Participants will be notified in writing of the outcome of the appeal committee's review. The decision of the appeal committee shall be final and binding on all parties.