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69 11/2005
Appeal Examples:
Medical
1. The care does not meet the medical guidelines for medical necessity,
appropriateness, health care setting, level of care or effectiveness
2. Services were determined to be experimental or investigational
3. Contract exclusions that require a clinical interpretation, such as cosmetic
versus reconstructive procedures and pre existing conditions
Administrative
1. Services were not covered based on any plan exclusion that does not require a
clinical interpretation
2. Services were not covered based on any plan limitation
3. A determination that the person was not eligible to participate in the plan
• Grievance: A formal complaint that is not an appeal and that involves a matter
other than an adverse benefit determination, including the quality of health
care services or administrative services received by the enrollee. A grievance is
not related to the denial of benefits for healthcare services. A grievance should
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 grievances is otherwise required by the nature of the
grievance, state or federal law, or accreditation guidelines.
Grievance Examples
:
1. The availability, delivery or quality of health care
2. The handling of a claim payment or benefit determination
3. The contractual relationship between the member and health plan