Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 15 - Mississippi Health Carrier External Review Regulation › Rule 19-3-15.20 - Appendix A - Notice of Appeal Rights

Current through June 25, 2024
NOTICE OF APPEAL RIGHTS
You have a right to appeal any decision we make that
				  denies payment on your claim or your request for coverage of a health care
				  service or treatment.
You may request more explanation when your claim or
				  request for coverage of a health care service or treatment is denied or the
				  health care service or treatment you received was not fully covered.
Contact1 us when you: " Do not understand the reason
				  for the denial;
* Do not understand why the health care service or treatment
				  was not fully covered;
* Do not understand why a request for coverage of a health
				  care service or treatment was denied;
* Cannot find the applicable provision in your Benefit Plan
				  Document;
* Want a copy (free of charge) of the guideline, criteria or
				  clinical rationale that we used to make our decision; or " 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 health care 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 [insert address of where appeals should be sent to the health
				  carrier] within
180 days
of the date you receive our
				  denial.2 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
60 days
of receiving your
				  appeal.3 If you do not receive our decision within
60 days
of receiving your appeal, you may be entitled to file a
				  request for external review.4
External Review4:
We
				  have denied your request for the provision of or payment for a health care
				  service or course of treatment. You may have a right to have our decision
				  reviewed by independent health care professionals who have no association with
				  us if our decision involved making a judgment as to the medical necessity,
				  appropriateness, health care setting, level of care or effectiveness of the
				  health care service or treatment you requested by submitting a request for
				  external review within
4 months
after receipt of this notice to
				  the Office of the Insurance Commissioner, Mississippi Insurance Department,
				  Attn: Life and Health Actuarial Division, P.O. Box 79, Jackson, MS 39205,
				  Phone: (601) 359-3569. 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 health care 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 your state insurance department.
				  1
1 See address and telephone number
				  on the enclosed Explanation of Benefits if you have questions about this
				  notice.
2 Unless your plan or any
				  applicable state law allows you additional time.
3 Some states and plans allow you
				  more (or less) time to file an appeal and less (or more) time for our decision.
				  See your Benefit Plan Document for your state's appeal process.
4See your Benefit Plan Document
				  for your state's appeal process and to determine if you're eligible to request
				  an external review in your state (e.g. some state appeal processes require you
				  to complete your insurer's appeal process before filing an external review
				  request unless waived by your insurer; while some states do not have such a
				  requirement).
Miss. Code Ann. §
										83-5-1
				  (Rev. 2011); Public Law
				  111-148 -Mar. 23, 2010 (Patient Protection and
				  Affordable Care Act)