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68 11/2005
• Inquiry: A request (in writing, telephonically, or by any other electronic means)
made by one of our customers (members, payors, brokers/agents, physicians,
health care institutions and other health care clinicians, or their authorized
representative) to the health plan for additional information or clarification
regarding benefit coverage, how to access medical care/covered benefits, etc.
It is an informational request handled at the point of entry, or that is forwarded
to the appropriate operational area for final response. It is not a complaint,
appeal, or grievance.
• Complaint: An expression of dissatisfaction (in writing, telephonically, or by
any other electronic means) from the member or from a representative on
behalf of the member that is handled at the point of entry, or that is forwarded
to the appropriate operational area for final response. It is not an appeal or
grievance.
• Appeal: A formal request (in writing, telephonically, or by any other electronic
means) for review of an adverse benefit determination (a denial, reduction or
termination of benefit coverage for healthcare services). An appeal should be
always be documented in writing. It should also be required to be submitted in
writing by the enrollee or the enrollee’s representative, except where the
acceptance of oral appeals is otherwise required by the nature of the appeal
(e.g. urgent care claims), state or federal law (e.g. California, Georgia) or
accreditation guidelines.
Types:
1. Standard – described above.
2. Expedited – a dispute about an initial determination and/or utilization
management denial which member and/or member representative believes
may jeopardize the member’s health, life or ability to regain maximum
function if reviewed under timeframes of standard determination process.