State and Public Schools’ Health Insurance Plan
If you believe Blue Cross Blue Shield incorrectly denied all or part of a claim, and you want to obtain a review, you must request a review in writing from Blue Cross Blue Shield. You have 60 days to request a review after receiving notice of denial. After this timeframe, your right to review is forfeited. After receipt of the claim, the decision will be sent to you in writing should the claim be denied again for payment. Reason will be provided with reference to the Plan provisions on which the decision is based.
Should you disagree with BCBS’s determination, you may submit your final appeal in writing to the Department of Finance and Administration, Office of Insurance within 30 days of the second denial. Your request should include a copy of Blue Cross Blue Shield’s review decision and all information pertinent to the claim.
Utilization Review Process
You or your provider may initiate the reconsideration process. The process is as follows:
Step 1: The attending physician contacts CareAllies/Intracorp to discuss any findings of “not medically necessary”. Based on that discussion, a second CareAllies/Intracorp staff physician will determine whether the original decision should be affirmed or amended. The enrollee and attending physician will be notified in writing of the results of this review.
Step 2: When a disagreement between the attending physician and CareAllies/Intracorp staff physician is not resolved as a result of Step 1, the patient/enrollee or the attending physician may submit to CareAllies/Intracorp a written request for review, which outlines the reason for the request. A thorough review and discussion of medical records and other supporting documentation will be undertaken. Based on that review, a decision affirming or amending the original decision will be rendered and provided in writing to the enrollee and the attending physician.
Step 3: If the attending physician or the patient/enrollee is not satisfied with the outcome of Step 2, either of them may request an independent review by an independent physician under contract with CareAllies/Intracorp to conduct such reviews. The decision of the independent physician is final and not subject to further consideration.
Concurrent review is the process of review that occurs before medical services are provided. Its purpose is to help ensure that only quality, medically necessary services are provided. This review may result in a determination that reimbursement will be reduced or denied under certain circumstances.
Prospective review occurs after medical services have already been provided. Its purposes is to help ensure that only quality, medically necessary services are provided. This review may result in a determination that reimbursement will be reduced or denied under certain circumstances.
Retrospective review occurs after medical services have already been provided. This review may result in a determination that reimbursement will be reduced or denied under certain circumstances. A retrospective review is performed when CareAllies/Intracorp is contacted after discharge from an inpatient admissions or 48 or more hours after an outpatient diagnostic test requiring certification was performed.
If a participant believes that Catamaran Rx incorrectly denied all or part of a prescription drug claim, he has the right to obtain a full and fair review. A request for review must be made in writing to Catamaran Rx.
The participant has 60 days from receiving notice of denial from Catamaran Rx to request a review. If the participant fails to request a review within this timeframe, the right to review is forfeited.
After the claim has been reviewed, if benefits are again denied, the decision will be sent to the participant in writing. The letter will include the reason(s) why benefits are denied, with reference to the Plan provisions of which decision is based.
If, after following the appeal procedure described above, the participant still disagrees with the determination, a final appeal may be submitted in writing to the Department of Finance and Administration, Office of Insurance within 30 days of the second denial. The request to the Office of Insurance must include a copy of the Catamaran Rx review decision and all information pertinent to the claim. The decision of the State Insurance Administrator with the Department of Finance and Administration, Office of Insurance is final and concludes all administrative levels of appeal.
Failure to request a review within the above time framed and in accordance with the procedures will result in the participant’s right to an appeal and rights to sue being forfeited.
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Prescription Drug Appeals