Home | Contact Us | Quick Form Access
Medical Review Request Form

Appeal Procedure

A provider or member may appeal the decision of Corporate Systems Managed Care regarding the medical necessity for insurance purposes.   Appeal re-considerations can include decisions related to hospitalization, medical services, length-of-stay issues, and/or claim processing decisions.
Appeal Review Worksheet
In all cases, the appeal process is the same.   The member and provider is notified in writing of the decision within seventy-two (72) hours and copies are sent to the provider and the enrollee.   In the event of an adverse decision (denial), the member may appeal by requesting reconsideration by telephone or in writing up to one-hundred eighty (180) days after receiving the adverse ruling.

Appeal Level 1:
Upon receiving an appeal of an adverse decision, an advisory board representative for CSA will call the provider within forty-eight (48) hours to discuss the case further and possibly request additional documentation. If additional documentation isn't received in forty-eight (48) hours after an attempt has been made, reconsideration on the appeal will be done without further input.

Within seventy-two (72) hours after discussing the case with the provider and/or member, and receiving any requested documentation, the advisory board will issue a written response to the appeal.   The decision is communicated to the provider and enrollee by telephone and in writing.

Appeal Level 2:
If the member is still dissatisfied with the determination the case can be referred to an outside consultant for further review.   All relevant information will be reviewed, discussion with the physician advisor and provider may take place, and a recommendation to the physician advisor will be made within fifteen (15) days.

The above, notwithstanding, it should be understood that Corporate Systems Managed Care determines medical necessity for the purpose of insurance reimbursement only.   The treating physician has sole responsibility for the ultimate health and safety of the patient.

Determinations for medical necessity are based upon widely accepted clinical criteria.   Authorizations do not guarantee payment or certification of coverage or eligibility.   All payments are subject to the determination of eligibility/coverage at the time service is rendered in accordance to the plan document.
Certification
Request Form
Information Release Consent Form
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. All determinations for Medical Necessity are based upon widely accepted clinical criteria. All payments are subject to the determination of eligibility and coverage at the time service is provided and not guaranteed.