SelectHealth | Total Fitness | Winter 2016

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We are committed to making sure all
concerns or problems are investigated
and resolved as soon as possible. Most
situations can be resolved by contacting
Member Services.
FORMAL APPEALS PROCESS
If you disagree with a decision that
adversely affects your coverage or benefits,
you or an authorized representative
has the right to appeal the decision in
writing by faxing the information to
801-442-0762 or mailing it to the
following address:
Attn: Appeals
SelectHealth
P.O. Box 30192
Salt Lake City, UT 84120-8212
If you wish for another individual,
including an attorney, to represent you
through any level of the formal appeals
process, you must provide written
authorization on an Authorization to
Disclose Health Information Form to
release information to the authorized
representative. You can complete a copy
of this form by visiting .
All written appeals should be addressed
to the SelectHealth Appeals department
within 180 days from the date of
notification of the denial to be eligible
for review through the formal appeals
process. Upon receipt, the appeal will be
investigated by our Appeals department
and reviewed by individuals who were not
involved in the initial determination.
If the adverse benefit determination was
based on medical judgment, the appeal
will be reviewed by at least one healthcare
provider working in the same or a similar
specialty. This person typically treats
the medical condition, performs the
The appeals process
What to do if you
disagree with a
SelectHealth decision
procedure, or provides the treatment
in question.
Written notification of the decision will
be completed no later than 30 calendar
days from the date we receive the appeal.
If the appeal involves coverage of a service
or treatment for an urgent condition,
you or your provider may request an
expedited review. If your condition meets
the criteria for an expedited review, you
will be notified of the decision within
72 hours of the request.
If you are appealing a final internal
adverse benefit determination, you
may request that an Independent
Review Organization (IRO) perform
an external review of your appeal.
An IRO review applies only to the
following considerations:
• Medical necessity
• Appropriateness
• Healthcare setting
• Level of care
• Effectiveness of a covered benefit
• Utilization review
• Experimental and/or
investigational services
• Rescission of coverage
An IRO is a review organization that
is not connected in any way to us. The
IRO employs healthcare providers with
the appropriate level and type of clinical
knowledge to properly judge an appeal. It
is our (not your) responsibility to pay for
the costs of the external review process.
OTHER COMPLAINTS
If you have a complaint related to
SelectHealth or one of our participating
providers that does not involve coverage
or payment of a claim, contact Member
Services. These complaints might involve
the quality of the care or customer
service you received. You may file your
complaint by phone, in writing, or in
person. We will look into your complaint
and provide you with an answer as
soon as possible but typically no later
than 30 calendar days from the day
SelectHealth receives the complaint.
When filing a complaint, please provide
a summary of the complaint with enough
detail to allow SelectHealth to research
the issue, and a description of the action
you are requesting.
For more information, please
call the Appeals department
at 844-208-9012.
Coverage
decisions
Our Utilization Management
department makes coverage
decisions based only on
appropriateness of care and
service and existence of
coverage. We do not reward
providers or other individuals
for issuing denials of coverage
or care.
| Winter 2016 | Total Fitness
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