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The Service You Deserve At Network Health, we work to ensure you’re receiving the service you need and deserve. If concerns arise, it's important for you to understand all your options.
When do I file an appeal?
You have the right to file an appeal if you do not agree with Network Health’s decisions about your health care. You can call or submit an appeal in writing within 60 calendar days of the date of your determination. Your written appeal should include your full name, member ID and information about what you are appealing. You may also include any comments, documents, records or other information you would like Network Health to consider in its review.
Examples of situations appropriate for an appeal include the following. • • •
Network Health did not approve care it should cover Network Health is stopping care you still need Network Health has denied payment for services or items you have received, and you think they should be covered
Who may file an appeal? You or someone you name to act for you (called your representative) may file an appeal. To name your representative, visit networkhealth.com/medicare/ member-resources and scroll down to the Appointment of Representative form. Simply complete this form and send it to us. A Durable Power of Attorney agreement can work in place of an Appointment of Representative form.
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What happens after I file an appeal? If you appeal, we will review our decision. If your request for service or claim payment is still denied after our review, we will automatically forward your Part C appeal to the Medicare independent review contractor. This process ensures you will receive a new and impartial review of your appeal. If you disagree with the independent review decision, you will be notified of further appeal rights.
How are medication appeals handled? Medication appeals are reviewed by a Network Health pharmacist and Network Health medical director, as needed. The pharmacist communicates with the prescribing provider if additional information is needed, or he/she may discuss alternative covered medications.
When do I file a grievance?
If you’re dissatisfied with the service or quality provided by your plan or doctor, we’re here to work with you through any issues. You have the right to file a grievance (a formal complaint) about the services provided by Network Health, our vendors or contracted providers.
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