Member Appeal Process

A multi-level process is available to the member to resolve any complaints or grievances regarding a claim denial or other action by Regence. In addition, if the member or member’s physician reasonably believes that a utilization management decision made denying pre-authorization of a service could jeopardize the member’s life, health or ability to regain maximum function or, in the opinion of a physician with knowledge of a member’s condition, would subject the member to severe pain that cannot be adequately managed without the disputed care, the member may request an expedited appeal. When an expedited appeal is initiated, a full description of the expedited appeal process will be provided.

FIRST LEVEL
Reconsideration
The member may initiate an appeal through either a written or oral request. Written appeal requests should be mailed to the Appeal Coordinator, Regence, PO Box 30270, Salt Lake City, Utah 84130-0270. Oral requests can be made by calling Regence at (801) 333-2100 within the Salt Lake area or 1 (800) 624-6519 outside the Salt Lake area. Within seven days of the request for an appeal, Benefits Administration will send information to the member describing the entire member appeal process and the member’s rights. Reconsideration is a review by Benefits Administration, and the usual timeframe for decision is within 30 days of receipt of the appeal, although some types of appeals are subject to a shorter decision timeframe.

SECOND LEVEL
Internal Appeal
If the member disagrees with the reconsideration decision, the member may request further appeal to the “Second Level - Internal Appeal.” The appeal request, which may be written or oral, must be made within 180 days of the member’s receipt of the reconsideration decision or the right to internal appeal will be lost. Written appeal request, including any additional information or comments, must be mailed to the Appeal Coordinator, Regence, P.O. Box 30270, Salt Lake City, Utah 84130-0270. Oral requests can be made by calling Regence at (801) 333-2100 within the Salt Lake area or 1 (800) 624-6519 outside the Salt Lake area. Within seven days of the request for Internal Appeal, the Appeal Coordinator will send information to the member describing the entire Member Appeal Process and the member’s rights. Internal Appeal is a review by a panel composed of the Appeal Coordinator, a Regence Medical Services physician, and another officer of Regence. The member or a representative will be given a reasonable opportunity to participate and/or provide written materials. The usual timeframe for decision is within 30 days of receipt of the appeal, although some types of appeals are subject to a shorter decision timeframe.

OPTIONAL THIRD LEVEL
External Appeal
If the member disagrees with the Internal Appeal decision, the member may request further appeal to the “Third Level - External Appeal.” The appeal request, which may be written or oral, must be made within 180 days of the member’s receipt of the Internal Appeal decision or the right to external appeal will be lost. Written appeal, including any additional information or comments, must be mailed to the Appeal Coordinator, Regence, P.O. Box 30270, Salt Lake City, Utah 84130-0270. Oral requests can be made by calling (801) 333-2100 within the Salt Lake area or 1 (800) 624-6519 outside the Salt Lake area. External Appeal will be coordinated by the Appeal Coordinator while the decision is made by an Independent Review Organization (IRO). The IRO is an independent physician review organization that is unbiased, independent and not controlled by Regence. Within five days of the request for the External Appeal, the Appeal Coordinator will send information describing the entire Member Appeals Process and the member’s rights. The usual timeframe for decision is within 30 days of receipt of the appeal. The IRO’s decision is binding and further appeal to arbitration is not permitted.

FOURTH LEVEL
Binding Arbitration
As an alternative to External Appeal, voluntary binding arbitration is available as a final level of appeal for a dispute the member has with Regence. All other (non-optional) levels of this Member Appeal Process must be exhausted before arbitration is available. When the member chooses binding arbitration, the member agrees to give up the right to a jury or court trial for the settlement of such disputes, and agrees that any dispute will be resolved by the binding arbitration. The Appeal Coordinator can assist the member with procedures for initiating and participating in arbitration.

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