You have a right to appeal any decision we make that denies payment on your claim or your request for coverage of a healthcare service or treatment. You may request more explanation when your claim or request for coverage of a healthcare service or treatment is denied or the healthcare service or treatment you received was not fully covered. Contact us when you:
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Do not understand the reason for the denial;
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Do not understand why the healthcare service or treatment was not fully covered;
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Do not understand why a request for coverage of a healthcare service or treatment was denied;
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Cannot find the applicable provision in your Benefit Plan Document;
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Want a copy (free of charge) of the guideline, criteria or clinical rationale that we used to make our decision; or
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Disagree with the denial or the amount not covered and you want to appeal.
If your claim was denied due to missing or incomplete information, you or your healthcare provider may resubmit the claim to us with the necessary information to complete the claim.
Appeals: All appeals for claim denials (or any decision that does not cover expenses you believe should have been covered) must be sent to: CoOportunity Health, Member Services Department, 8170 33rd Avenue South, P.O. Box 1309, Minneapolis, MN 55440-1309 within 180 days of the date you receive our denial. We will provide a full and fair review of your claim by individuals associated with us, but who were not involved in making the initial denial of your claim. You may provide us with additional information that relates to your claim and you may request copies of information that we have that pertains to your claims. We will notify you of our decision in writing within 30 days of receiving your appeal. If you do not receive our decision within 30 days of receiving your appeal, you may be entitled to file a request for external review. You may telephone us at 1.888.324.2064 if you need assistance in submitting your appeal.
External Review: Once you have completed the internal grievance process as set forth in the Health Carrier Grievance Procedure Act described above, you may be entitled to an External Review of your claim denial. You may not have to complete the internal grievance process if you are entitled to an expedited external review of the adverse determination. The expedited external review may be requested once the internal appeal has been filed with the health carrier. We have denied your request for the provision of or payment for a healthcare service or course of treatment. You may have a right to have our decision reviewed by independent healthcare professionals who have no association with us if our decision involved making a judgment as to the medical necessity, experimental or investigational nature, appropriateness, healthcare setting, level of care or effectiveness of the healthcare service or treatment you requested by submitting a request for external review within 4 months after receipt of this notice to the appropriate state insurance division.
Iowa Members
Iowa Insurance Division
601 Locust Street, 4th Floor
Des Moines, IA 50309-3738
Telephone: 1.877.955.1212 or 515.281.6348
Fax: 515.281.3059
Website: www.iid.state.ia.us
E-mail: [email protected]
You may contact the Iowa Insurance Division for more information. In addition, the forms may be accessed on the Iowa Insurance Division Website at www.iid.state.ia.us/. For standard external review, a decision will be made within 45 days of receiving your request. If you have a medical condition that would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed, you may be entitled to request an expedited external review of our denial. If our denial to provide or pay for healthcare service or course of treatment is based on a determination that the service or treatment is experimental or investigation, you also may be entitled to file a request for external review of our denial. For details, please review your Benefit Plan Document, contact us or contact the Iowa Insurance Division.
Nebraska Members
Nebraska Department of Insurance
P.O. Box 82089
Lincoln, NE 68501-2089
Telephone: 1.877.564.7323
Website: www.doi.nebraska.gov
You may contact the Department of Insurance for more information. In addition, the forms may be accessed on the Department of Insurance Website at www.doi.nebraska.gov. For standard external review, a decision will be made within 45 days of receiving your request. If you have a medical condition that would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed, you may be entitled to request an expedited external review of our denial. If our denial to provide or pay for healthcare service or course of treatment is based on a determination that the service or treatment is experimental or investigation, you also may be entitled to file a request for external review of our denial. For details, please review your Benefit Plan Document, contact us or contact the Nebraska Department of Insurance.