6.5.4
REQUEST FOR REVIEW OF DENIAL OF BENEFITS BASED ON PRECERTIFICATION
REVIEW
Regular Request for Review
If the Utilization Management Organization determines
that the proposed service is not Medically Necessary,
you and/or your Physician may submit a written request
for review accompanied by any additional information to
support the need for the proposed service.
The request for review should be sent to the Utilization
Management Organization. You can expect that the Utilization
Management Organization will respond in writing within
30 days after receiving the request and any required medical
records and/or information.
Expedited Request for Review
If the Utilization Management Organization determines
that the proposed service is not Medically Necessary,
the treating Physician may telephone the Utilization Management
Organization to request an expedited review with the medical
director or a Physician designated by the Utilization
Management Organization to provide the necessary review.
the Utilization Management Organization will usually respond
to your Physician by telephone within 24 working hours,
and later confirm the determination in writing to you,
your Physician, and the Administrative Office.
Independent Review of a Denial of Precertification
If the Utilization Management Organization confirms
the initial determination that the proposed service is
not Medically Necessary, you and/or your Physician may
submit a written request for an independent medical review
of the denial of precertification. Call the Trust Customer
Service Office for information regarding this independent
review. The independent medical reviewer will consider
all information presented by your Physician and the Utilization
Management Organization. You can expect a written response
regarding this review from the Trust within 60 days after
your request for such a review is received.
If the independent medical reviewer determines the service
is not Medically Necessary, you may request review by the
Appeals Committee pursuant to the Review Procedure explained
at Section 6.5.4.
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