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Appeals

About Meritain Health’s Claims Appeal Procedure                                                        

                                                                                                                                              

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.

The below link should be used by a member who would like to appoint an authorized representative to appeal an adverse benefit on their behalf. The link contains two forms and instructions on how to fill out one of the forms. The other form is self explanatory. The member would need to submit the form to the provider with submission of 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.

 

Authorization for Release of Protected Health Information                                                             

 

Please note, the claims appeal procedure is explained at length within each group’s Summary Plan Description (SPD).