Respond to appeals from the involved health plan within 24 hours for Expedited Appeals and 7 calendar days for Routine Appeals. Assemble the denial packet response including the cover letter outlining the findings, member’s medical records, a copy of the denied referral request, a copy of the denial letter and rationale for initial decision. Present overturned cases to Medical Director for approval to issue authorization per health plan demand. Log all appeals in to the database for monthly tracking as well as Quarterly Appeals Trending Report to be presented to the Quality Improvement Committee (QIC).
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