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Administrative Manual

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Regence Member Appeal Policy and Procedures

The Regence Member Appeal Policy applies to all insured group and individual contracts issued by Regence, with the exception of Federal Employee Program (FEP), Medicare beneficiaries, Medicaid and certain other government programs. Self-funded plans establish their own appeal processes. Please contact Customer Service for details. An appeal must be initially submitted to Regence within 180 days of the member’s receipt of the claim denial or other action giving rise to the complaint or grievance. Failure to initiate appeal within this time period (absent the Plan’s finding, in its sole discretion, of acceptable extenuating circumstances) will preclude all further rights to appeal and may jeopardize the member’s ability to contest the denial or other action in any forum. All applicable non-optional appeal levels must be exhausted before the member may contest the action in any forum, including through filing a lawsuit.

“Appeal” includes any grievance, complaint, reconsideration or similar terms as used in some jurisdictions, and is a written or oral request from a member, their personal representative, treating provider or appeal representative, to change a previous decision (Adverse Benefit Determination) made by Regence concerning:

  1. access to health care benefits, including an adverse determination made pursuant to utilization review;
  2. claims payment, handling or reimbursement for health care services;
  3. matters pertaining to the contractual relationship between a member and the Plan; or
  4. other matters as specifically required by law or regulation..

“Appeal representative” is a representative of the member for the purpose of the appeal. The appeal representative may be the member’s treating provider, personal representative, or another party, such as a family member, for whom the member or their personal representative has signed a valid authorization. If no such authorization exists and is not received in the course of the appeal, the determination and any personal information will be disclosed to the member, their personal representative or treating provider only.

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“Personal representative” means a person who is legally authorized to act on behalf of an individual for health care decisions. For example: parents of a minor; a person holding a power of attorney; conservator; or person appointed by a court; so long as the power granted to the person includes managing the individual’s health care affairs.
“Authorization” is an individual’s written permission for use and disclosure of their personal information for a specific purpose and timeframe in accordance with the Regence Privacy Policy.

“Adverse benefit determination” means a determination by Regence, or its designee utilization review organization, that an admission, availability of care, continued stay or other covered health care service has been reviewed, and based upon the information provided, does not meet the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care, effectiveness or has been determined to be an investigational service, and the requested service or payment for the service is therefore terminated, denied or reduced.

“Urgent care request” is a claim relating to an admission, availability of care, continued stay or healthcare service for which the covered person received emergency services but has not been discharged from a facility, or any pre-service or concurrent care claim for medical care or treatment for which the application of the time periods for making regular appeal determinations:

  1. could seriously jeopardize the life or health of the member or the ability of the member to regain maximum function;
  2. in the opinion of a physician with knowledge of the members medical condition, would subject the member to severe pain that cannot be adequately managed without the disputed care or treatment; or
  3. the treatment would be significantly less effective if not promptly initiated.

An individual acting on behalf of the Plan applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine may determine whether a request is an urgent care request. However, the determination by a physician with knowledge of the member’s medical condition that a request is an urgent care request is binding. 

View additional member appeal information:

Appeal Levels One, Two and Three
Expedited Appeals
Member Rights and Responsibilities

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Revised July 2011