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CareAllies has a standard three-level appeals process that handles:
- medical necessity service denials
- expedited process to address emergent or ongoing care situations
We follow state-specific, jurisdictional, and DOL/ERISA mandates related to this process, and these mandates determine if non-standard levels of appeal would apply.
First Level Appeals
Who can request
The provider, facility, claims payor, or patient/claimant within 365 days from date when the last determination was issued.
How to appeal
Appeals can be requested either verbally or in writing, by fax or mail.
Mail appeal requests to:
CareAllies Appeal
1777 Sentry Park West
Dublin Hall 4th Floor
Blue Bell, PA 19422
Fax to Appeal Department at 860.847.5105
Phone 800.232.7497 and an Appeals Case Associate will assist you.
CareAllies Process
- We acknowledge receipt in writing within two calendar days.
- Expected completion of the process is fifteen calendar days for prospective appeal, and thirty calendar days for retrospective appeal.
- A medical director of appropriate specialty, who was not involved with the initial denial decision, reviews the case. If we request additional information to complete the appeal review, the timeframe is extended by fifteen calendar days and an extension letter is sent.
- Second level appeals offer committee review when required by jurisdiction.
- Third level review is conducted by an External Independent Review Entity.
Expedited Appeals
An Expedited Level One or Level Two Medical Necessity Appeal is available when a delay might jeopardize life, health, or ability to regain maximum functionality of the Member, or when requested due to failure to authorize a continuing inpatient hospital stay.
- Standard turnaround time for an expedited appeal is 72 hours from request.
Non-Standard Appeals
State specific requirements are followed for all non-standard processes. Non-standard appeal processes and timelines are followed whenever state-specific, jurisdictional, or DOL/ERISA mandates apply.
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