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.
- 1. Initial Appeal to the Plan Administrator
- 2. Appeal of the Plan Administrator's Decision to DCMS Group Insurance Division.
- 3. For Medical Necessity Appeals only; Final Review by DCMS Appeal Committee