2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 74
(1)
The 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 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 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 Plan will identify any medical or vocational experts whose advice is obtained on behalf of the Plan in
connection with the 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 Plan's determination on review, will be
transmitted between the 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 claim and to submit issues and comments relating to the claim in writing
to the Plan. The reviewer will take into account all comments, documents, records and other information
submitted by the claimant relating to the claim 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.
Appeals Department
P. O. Box 41980
Plymouth, MN 55441-0970
Deadline for Internal Review and Appeal of Initial Adverse Benefit Determinations
(1)
Urgent Care Claims. The Plan provides for 2 levels of appeal for urgent care claims. For each level of appeal,
the reviewer will notify you of the Plan's determination on review as soon as possible, taking into account the
medical exigencies, but not later than 36 hours after the Plan receives your request for review of the initial
Adverse Determination (or of the first-level appeal Adverse Determination).
(2)
Pre-Service Claims. The Plan provides for 2 levels of appeal for a pre-service claim. At each level of appeal,
the reviewer will notify you of the Plan's determination on review within a reasonable period of time appropriate
to the medical circumstances, but in no event later than 15 days after the Plan receives your request for review
of the initial Adverse Determination (or of the first-level appeal Adverse Determination).
(3)
Post-Service Claims. The Plan provides for 2 levels of appeal for a post-service claim. At each level of appeal,
the reviewer will notify you of the Plan's determination on review within a reasonable period of time appropriate
to the medical circumstances, but in no event later than 30 days after the Plan receives your request for review
of the initial Adverse Determination (or of the first-level appeal Adverse Determination).
70