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Appeals Process

Medical Necessity Appeals

An appeal is the request for review of a “Notice of Adverse Action.” 

A “Notice of Adverse Action” is the denial or limited authorization of a requested service, including the:

  • Type or level of service.
  • Reduction, suspension, or termination of a previously authorized service.
  • Denial, in whole or part of payment for a service excluding technical reasons.
  • Failure to render a decision within the required timeframes.
  • Denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the Buckeye Health Plan network.

Appeal Resolution Time Frame

The review may be requested in writing or orally and will be resolved within 30 days.

  • Oral requests for appeals within the standard timeframe, must be resolved within 30 days of receipt of the appeal.
  • Members may request Buckeye to review the Notice of Adverse Action to verify if the right decision has been made.

Expedited appeals: may be filed for a pre-service denial when either Buckeye Health Plan or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal.

If a member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals.

Decisions for expedited appeals:

  • Are issued as expeditiously as the member’s health condition requires, to not exceed 72 hours from the initial receipt of the appeal.
  • A 14 calendar day extension may be added by Buckeye
    • If the member requests the extension, or
    • If Buckeye provides evidence satisfactory to the Department of Health Services (DHS) that a delay in rendering the decision is in the member’s interest.
  • For any extension not requested by the member:
    • Buckeye will provide written notice of the reason for delay to the member
    • Buckeye will make reasonable efforts to provide the member with prompt verbal notice of any decisions not resolved wholly in favor of the member and will follow-up in writing within two calendar days of action.