A pre-service appeal is a request to change a denial of coverage for a planned health care service. The member’s rights in the member’s benefit plan govern this process. You can submit normal pre-service appeal requests through the standard fax line or mailed to the address in the pre-service denial letter. A peer-to-peer review is highly recommended before you file a pre-service appeal.
If you have already provided the service, an expedited or urgent appeal is not available. Submit a claim based on the service provided. See the appeal section for more information.
You may request an urgent pre-service appeal on behalf of the member by using the urgent appeals fax number listed in the pre-service denial letter. We consider requests urgent when:
If we request medical records to process an appeal, you must provide the information within the following time frames. This includes providing a copy of the denial notice.