Coverage and Claims Appeals

A coverage decision is a decision Group Health makes about your benefits and coverage, or about the amount we will pay for your medical services. If you are denied coverage for a medical service or payment of a medical claim, you have the right to appeal that decision.

Group Health has a formal internal appeals process for review of member coverage and claims disputes. Disputes are reviewed through a first-level appeal process, with an optional second-level review available. Unless your contract states otherwise, you will be able to use Group Health's first-level and optional second-level processes.

Appeals that are not resolved to your satisfaction may be eligible for independent review by a state-certified independent review organization. Group Health pays for the review and must abide by the independent review organization's decision. Medicare and federal plan members follow the independent review process administered by the Medicare and federal programs. Please refer to your current coverage agreement for more specific information regarding your appeal rights.

How to Initiate an Appeal

If you want to initiate an appeal or learn more about your appeal rights:

Complete our Member Appeals Request form and return it to our Member Appeals department:

Fax: 206-901-7340

Mail:
Group Health Member Appeals
P.O. Box 34593
Seattle, WA 98124-1593
AMB-2 Appeals

• Member Appeals Request form (PDF)

Alternatively, you can fill out and submit a request online. (To protect the security of your personal information, you must log in to MyGroupHealth to access the online form.)

• Online Member Appeals Request form

If you need help, please call 1-866-458-5479.

Expedited Reviews

You or your physician can ask for a fast review. When a delay would seriously threaten your health, reviews can be expedited and a determination usually issued within 24-72 hours depending on your plan requirements. If you are requesting a "fast appeal," please call Member Appeals at 1-866-458-5479.

Requests on Behalf of a Member

If you are submitting a request on behalf of the member receiving the service, complete and sign the following Group Health member appeals forms:

• Member Appeals Request (PDF)
• Authorization to Release Health Care Information (PDF)
• Authorization for the Release of Specifically Protected Confidential Information (PDF) (if the request is for sexual reproduction or disease, mental health, or chemical dependency)
• Appointment of Representative (for non-Medicare members) (PDF)
• Appointment of Representative (for Medicare members) (PDF)

If the member is unable to sign the Appointment of Representation or Authorization to Release Health Care Information forms, you must send a Healthcare and/or Financial Dependent Power of Attorney stipulating that you are currently authorized to appeal on behalf of the member.

If you are the "treating provider" submitting this request on behalf of the member, you must provide us with an Appointment of Representative form signed by both you and the member, and an Authorization to Release Health Care Information form signed by the member.

If the denial document states the payment is the provider's responsibility, not the member's, then the provider must submit a reconsideration request in writing to the Provider Assistance Unit. The member may not appeal on behalf of the provider.