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 or plan-specified entity. Group Health pays for this review unless provided through the specific purchaser and must abide by the independent review organization's decision. Self-funded plans may offer one level of internal appeal through Group Health and must provide for an independent review at next level. Plans in Idaho include a Group Health appeal board review on initial appeal and an independent review through an organization assigned by the Idaho Department of Insurance.
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:
By Fax or Mail
If you need help, please call 1-866-458-5479.
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. You may also request a simultaneous independent review for some plans. If you are requesting a fast appeal, please call Group Health's Member Appeals Unit 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:
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.