This is called an appeal . The other appeal route occurs when a member is unhappy with other aspects of the plan's operations. A complaint about other operations of the plan is called a grievance .
Members have the right to two levels of review, for both appeals and grievances.
However, the second-level review is the same regardless of whether the dispute is a denial of services or another problem with the plan's operation. This is referred to as a second-level grievance hearing. Otherwise the normal time limits apply. When health plans deny care, they must send the covered member a non-certification letter explaining why the requested service or procedure was denied. Members should always ask for a copy of the clinical review criteria used in making the decision.