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; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service excluding technical reasons; the failure to render a decision within the required timeframes; or the 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, however oral requests for appeals within the standard timeframe must be resolved within 30 days of receipt of the appeal, with a 14 day extension possible if additional information is required. Members may request that Buckeye Health Plan review the Notice of Adverse Action to verify if the right decision has been made. Expedited appeals may be filed 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. In instances where the 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, not exceeding 72 hours from the initial receipt of the appeal. Buckeye Health Plan may extend this timeframe by up to an additional 14 calendar days if the member requests the extension or if Buckeye Health Plan 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 Health Plan shall provide written notice to the member of the reason for the delay. Buckeye Health Plan shall make reasonable efforts to provide the member with prompt verbal notice of any decisions that are not resolved wholly in favor of the member and shall follow-up within two calendar days with a written notice of action.