About Meritain Health’s Claims Appeal
Meritain Health’s claim appeal procedure consists of three levels:
- Level 1-Internal appeal. If a member submits a claim for coverage and it is initially denied under the procedures described within the group plan document, that member may request a review of the denial. Meritain Health allows 180 days after a member receives notice of an initial adverse determination to request a review of the adverse determination.
- Level 2-Internal appeal. Meritain Health allows 60 days to request a second-level appeal after a member receives notice of an adverse determination at the first level of appeal.
- Level 3-External appeal. If a member has exhausted the benefit plan’s internal appeal process (or a member is eligible to request an external review for any other reason) that member may request an external review of the benefit plan’s final adverse determination for certain health benefit claims. Meritain Health requires the member to complete an appeals form to indicate a request for external review. Once we receive the request form, the request for external review will be handled in accordance with federal law and/or state law, depending upon the benefit plan.
There are two forms listed below that a member must complete and give to the provider submitting the formal written appeal. The formal written appeal and these forms would then be sent to the address of the Meritain Health Appeals Department (listed on form) by the provider. Submission of these forms to the Meritain Health Appeals Department without a formal written appeal from the provider will not be reviewed.
Please note, the claims appeal procedure is explained at length within each group’s Summary Plan Description (SPD).
The form linked below should used by a member who would like to grant permission to another individual to act on their behalf in connection with an appeal.
The form linked below should be completed by a member who needs to grant access to their PHI to another individual in connection with an appeal.