2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 96
If you request a review of an Adverse Determination within the applicable time period, the review will meet the
following requirements:
(1)
The Dental/Vision Plan will provide a review that does not afford deference to the Adverse Determination
that is being appealed and that is conducted by an appropriate representative of the Dental/Vision Plan who
did not make the Adverse Determination that is the subject of the appeal and who is not a subordinate of the
individual who made that Adverse Determination.
(2)
The appropriate representative of the Dental/Vision Plan will consult with a health care professional who has
appropriate training and experience in the field of medicine involved in the medical judgment before making
a decision on review of any Adverse Determination based in whole or in part on a medical judgment, including
determinations with regard to whether a particular treatment, drug or other item is Experimental and/or
Investigational or not Medically Necessary or appropriate. The professional engaged for purposes of a
consultation in the preceding sentence will be an individual who is neither an individual who was consulted
in connection with the Adverse Determination that is the subject of the appeal, nor a subordinate of any such
individual.
(3)
The Dental/Vision Plan will identify any medical or vocational experts whose advice is obtained on behalf of
the Dental/Vision Plan in connection with the Dental/Vision Plan’s review of an Adverse Determination,
without regard to whether the advice is relied upon in making the Adverse Determination on review.
(4)
For a requested review of an Adverse Determination involving an urgent care claim, the review process will
meet the expedited deadlines described below. Your request for such an expedited review may be submitted
orally or in writing and all necessary information, including the Dental/Vision Plan's determination on review,
will be transmitted between the Dental/Vision Plan and you by telephone, facsimile or other available similarly
expeditious method.
(5)
The reviewer will afford you an opportunity to review and receive, without charge, all relevant documents,
information and records relating to the Adverse Determination and to submit issues and comments relating
to the Adverse Determination in writing to the Dental/Vision Plan. The reviewer will take into account all
comments, documents, records and other information submitted by the claimant relating to the Adverse
Determination regardless of whether the information was submitted or considered in the initial benefit
determination.
All requests for review of initial Adverse Determinations (including all relevant information) must be submitted to
the following address:
Meritain Health, Inc.
P.O. Box 853921
Richardson, TX 75085-3921
(800) 925-2272
Deadline for Internal Review and Appeal of Initially Denied Claims
Post-Service Claims. The Dental/Vision Plan provides for 2 levels of appeal for a post-service claim for Dental and
excluding Vision Materials reimbursement. At each level of appeal, the reviewer will notify you of the Dental/Vision
Plan's determination on review within a reasonable period of time appropriate to the health circumstances, but in
no event later than 30 days after the Dental/Vision Plan receives your request for review of the initial Adverse
Determination (or of the first-level appeal Adverse Determination).
Manner and Content of Notice of Decision on Internal Review of Initially Denied Claims
Upon completion of its review of an initial Adverse Determination (or a first-level appeal Adverse Determination),
the reviewer will give you, in writing or by electronic notification, a notice of its benefit determination. For an Adverse
Determination, the notice will include:
(1)
A description of the Dental/Vision Plan’s decision;
(2)
The specific reasons for the decision;
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