Claims Appeal or Pre - Authorization AppealIf you do not agree with the outcome of a processed claim or a pre-authorization request, you may submit an appeal/grievance online at www.gbg.com. (See Online Forms/Applications.) Alternatively, you can send a completed Appeal/Grievance Form (available at www.gbg.com) along with all the supporting documents to:
Email: customerservice@gbg.comMail: International Claims ServicesAttention: Appeals Department27422 Portola Parkway, Suite 110Foothill Ranch, CA 92610 USA
APPEALS PROCEDUREFor the purposes of this section, any reference to "you", "your", or Insured Person also refers to a representative or provider designated by you to act on your behalf, unless otherwise noted.
The company has a two-step appeals/grievance procedure for coverage decisions. To initiate an appeal, you must submit a request for an appeal/grievance in writing within 180 days of receipt of a denial notice. You should state the reason why you feel your appeal or grievance should be approved and include any information supporting your appeal/grievance. You may send it to the address above, or go to the website where you can complete an appeal form and submit it to us.
LEVEL ONE APPEALIf you are not satisfied with an administrative, eligibility, rescission of coverage, denial or reduction of benefit or if a medical care determination for pre-service or current care coverage has been denied; you or your appointed representative has the right to file an appeal or a grievance within 180 days.
Your appeal/grievance will be reviewed and the decision made by someone not involved in the initial decision. Appeals involving Medical Necessity, clinical appropriateness, or experimental and investigational will be considered by a medical care professional.
For Level One Appeals, we will respond in writing or electronically with a decision within fifteen calendar days after we receive an appeal for a required pre-service or concurrent care coverage determination (decision). We will respond within thirty calendar days after we receive an appeal for a post service coverage determination. If more time or information is needed to make the determination, we will notify you in writing or electronically to request an extension of up to fifteen calendar days and to specify any additional information needed to complete the review.
You may request that the appeal process be expedited if, (a) the time frames under this process would seriously jeopardize your life, health, ability to regain maximum function or in the opinion of your Physician would cause you severe pain which cannot be managed without the requested services; (2) or your appeal involves non-authorization of an admission or continuing inpatient stay. Our Medical Review Agent in consultation with the treating Physician will decide if an expedited review is necessary. When an appeal is expedited, we will respond within seventy-two hours, followed up in writing or electronically within (5) five days.
LEVEL TWO APPEAL If you are dissatisfied with our level one appeal decision, you may request a second review. To start a Level Two Appeal, follow the same process required for a level one appeal.
Most requests for a second review will be conducted by the Appeals Committee, which consists of at least three people. Anyone involved in the prior decisions may not vote on the committee. For appeals involving Medical Necessity, clinical appropriateness, or being experimental or investigational, the Committee will consult with at least one Physician reviewer in the same or similar specialty as the care under consideration, as determined by our medical review agent.
For level two appeals we will acknowledge in writing or electronically that we have received your request and schedule a Committee review. For required pre service and concurrent care coverage determinations, the Committee review will be completed within fifteen calendar days. For post service claims, the Committee review will be completed within thirty calendar days. If more time or information is needed to make the determination, we will notify you in writing to request an extension of up to fifteen calendar days and to specify any additional time needed by the committee to complete the review. You will be notified in writing of the decision within five working days of the meeting, and within the Committee review time frames.
You may request that the level two appeal process be expedited if, (a) the time frames under this process would seriously jeopardize your life, health, ability to regain maximum function or in the opinion of your Physician would cause you severe pain which cannot be managed without the requested services; (b) or your appeal involves non-authorization of an admission or continuing inpatient stay. Our medical review agent in consultation with the treating Physician will decide if an expedited review is necessary. When an appeal is expedited, we will respond within 72 hours, followed up in writing or electronically within (5) five calendar.
INDEPENDENT REVIEW PROCEDURE If you are not satisfied with the final adverse benefit determination decision of the level two appeal review regarding your Medical Necessity, clinical appropriateness, or experimental or investigational issue, you may request that your appeal be referred to an Independent Review Organization. The Independent Review Organization is composed of persons who are not employed by us or our administrator or any of our affiliates. A decision to use this external level of appeal will not affect the claimant’s rights to any other benefits under the plan.
There is no charge for you to initiate this independent review process. The Company will abide by the decision of the Independent Review Organization.
In order to request a referral to an Independent Review Organization, certain conditions apply. The reason for the denial must be based on a Medical Necessity or clinical appropriateness determination or because it is considered to be experimental or investigational by our medical review agent. Administrative, eligibility, or benefit coverage reductions or exclusions are not eligible for appeal under this process.
To request a review, you must notify the Appeals Coordinator within 180 days of your receipt of The Company’s final adverse benefit determination. The Company will then forward the file to the Independent Review Organization.
The Independent Review Organization will render an opinion within 30 days, when requested and when a delay would be detrimental to your condition, as determined by your physician and the external review agent, the review shall be completed within 72 hours upon receipt of required information.
