| Regular appeal process
- First Step: The Complaint
What the member must do:
You, or someone representing you, tell us, your
health plan (Asuris Northwest Health), about your
complaint in writing or verbally within 180 days
of receiving something in writing from us - such
as an Explanation of Benefits or letter denying
a pre-authorization request. Explain what you're
dissatisfied with based on a previous decision or
action by us. You may give us written materials
supporting your complaint. If you or your provider
is asking Asuris Northwest Health to reconsider
a previously denied pre-authorization, your provider
may be able to talk directly with a Medical Director.
What Asuris Northwest Health does:
A Member Service Specialist with contract benefits,
enrollment and claims processing expertise accepts
and logs the complaint and notifies you of receipt
within five days. The representative, working together,
as needed with a Medical Director, medical services,
legal or communication departments, investigates
the complaint, gathers facts and prepares a "complaint
package" of detailed information. Based upon
that package, the representative makes a decision,
records it in writing and sends a decision to you
within 30 days of first receiving your complaint.
That decision must be understandable, describe how
you may appeal the decision and the timing required,
list the people at our health plan who helped make
the decision, state the facts and refer to supporting
documents. After receiving this response, you may
ask us to reconsider by appealing the decision (See
Second Step).
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Second Step: Internal Appeal
What the member must do:
Tell us you want to appeal our decision (based
on your complaint) in writing or verbally within
180 days of receiving the decision notification
of your complaint. You may give us written materials
supporting your appeal and you are invited to appear
in person.
What Asuris Northwest Health does:
The appeal coordinator (Registered Nurse), working
as part of a "panel", accepts and logs
your appeal and notifies you within five days that
it was received. The panel consists of Company representatives
including the appeal coordinator, an administrative
representative who is a Member Service Specialist
with contract benefits, enrollment and claims processing
expertise and a Medical Director. Panel members
are new to the case and have not been involved in
any previous decision made regarding your original
complaint.
This panel may also coordinate with medical services,
legal and communication departments with the Company.
The Medical Director may also confer with an independent
physician with medical training related to your
appeal. The appeal coordinator investigates the
complaint, gathers facts and prepares an "appeal
package" of detailed information. The panel,
using this package and appropriate resources, makes
a decision on the appeal and records it in writing.
The decision is sent to you by certified mail within
30 days of first receiving your appeal. You'll get
the decision within 20 days if it's about an investigational
medical procedure and within 14 days if it's about
a service that your provider wants for you but needs
approval from our Company to perform. The written
decision must be understandable, describe how you
may request another appeal and the timing required,
list the people at Asuris Northwest Health who helped
make the decision, state the facts and refer to
support documents.
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Third Step: External Appeal
What the member must do:
Tell us you want to appeal our decision (based
on your complaint) in writing or verbally within
180 days of receiving the decision notification
of your complaint.
What Asuris Northwest Health does:
An appeal coordinator accepts and logs your appeal
and notifies you within five days that it was received.
The coordinator gathers all facts and supporting
documents together with the previous internal appeal
packet, and delivers it to an Independent Review
Organization (IRO) within three days of receiving
your request for an external appeal. An IRO, made
up of physicians not associated with our Company,
with medical training in the area of your appeal,
reviews your case and makes a decision. These physicians
are new to the case and have not been involved in
any previous decisions made about your complaint
or internal appeal. The IRO makes a decision, records
it in writing and sends it to us. Then, we notify
you by certified mail within 20 days of receiving
your initial appeal request. Our letter to you must
be understandable, describe the next appeal level,
if any, and the timing required, list the independent
physicians who made the decision, state the facts
and refer to support documents.
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Optional Step: Non-binding Mediation
An optional step may be available if your appeal
is denied at the third step. The letter that you
receive at the third step will describe non-binding
mediation and how to request the non-binding mediation
process.
If we fail to respond to you within 30 days to
you or your representative's written request to
have a complaint heard in person, you may proceed
as if your complaint has been rejected, including
submitting such complaint to a non-binding mediation.
Expedited appeal process
For members who need a faster process because of a
life-threatening medical condition, there is an expedited
appeal process. In this case, you go through an Internal
Appeal process similar to the one outlined above. The
difference is the reviewing "panel" is new
to the case, and they make a decision in one working
day or 72 hours, whichever is less after you tell us
that you want an expedited appeal. If you aren't satisfied
with that decision, you may ask for an expedited, second
level appeal similar to the External Appeal process
described above. The difference is the IRO makes a decision
in one working day or 72 hours, whichever is less after
you tell us that you want another expedited appeal.
Non-binding mediation may also be a final, optional
step in the expedited appeal process. We will tell you
if non-binding mediation is an option for you if the
second level expedited appeal is denied.
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