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Appeals

What is an Appeal?

An appeal is a way for you to challenge our action if you think we made a mistake. It is a formal way of asking us to review and change a coverage decision we have made.

You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision. If you miss the deadline for a good reason, you may still appeal.


Here is the step-by-step process for Level 1 Appeal

To start your appeal, you (or your representative or your doctor or other prescriber) must contact us.

Step 1

You contact us and make your Level 1 Appeal. If your health requires a quick response, you must ask for a "fast appeal".

When your complaint is about quality of care, you also have two extra options:

  1. You can make your complaint to the Quality Improvement Organization (QIO). If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our Plan). Livanta is California's QIO
  2. Or if you wish, you can make your complaint about quality of care to our Plan and also to the Quality Improvement Organization

For expedited requests (“fast appeal”): Please call or fax using the contact numbers above.

Step 2

When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We may contact you or your doctor or other prescriber to get more information.

Time Frames

Fast Appeal

For Medical Coverage Fast Appeal:
When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.

  • However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you in writing
  • If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. (See below for Level 2 Appeals Process)
  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal
  • If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal

For Drug Coverage Fast Appeal:
If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal . We will give you our answer sooner if your health requires it.

  • If we do not give you an answer within 72 hours, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we talk about this review organization and explain what happens at Level 2 of the appeals process
  • If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appeal
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision

Standard Appeal

For Medical Coverage:
For standard appeals, we will give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. We will give your our answer within 60 calendar days, if your appeal is for payment for services you have already received. We will give you our decision sooner if your health condition requires us to.

  • However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter
  • If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours

If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal.

For Drug Coverage:
For standard appeals, we will give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so.

  • If we do not give you a decision within 7 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization.

If our answer is yes to part or all of what you requested, we will do the following:

  • If the request is for prescription coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal.
  • If the request is to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.

Step 3

If our plan says no to part or all of your appeal, for medical services, your case will automatically be sent on to the next level of the appeals process, and for drugs, you will need to decide if you want to continue with the process and make another appeal.

For Medical Coverage:
We are required to send your appeal to the "Independent Review Organization." When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2.

For Drug Coverage:
If we say no to your Level 1 Appeal, the written notice we send you will include instructions on how to make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow, and how to reach the review organization.


Here is the step-by-step process for Level 2 Appeal:


Step 1

The Independent Review Organization reviews your appeal.

A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan

Time Frames


Fast Appeal

For medical coverage, if you had a "fast appeal" at Level 1, you will also have a "fast appeal" at Level 2.

For drug coverage, if your health requires it, you need to ask for a "fast appeal" and the Independent Review Organization needs to agree to give you a "fast appeal."

  • The review organization must give you an answer to your Level 2 Appeal within 72 hours of when it receives your appeal

For medical coverage, if you had a "standard appeal" at Level 1, you will also have a "standard appeal" at Level 2.


Standard Appeal

For drugs, if you don't ask for a "fast appeal", it will be a "standard appeal".

For medical services, the review organization must give you an answer to your Level 2 Appeal within 30 calendar days of when it receives your appeal. However, if the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days for both time frames.

  • For drugs, the review organization must give you an answer to your Level 2 Appeal within 7 calendar days of when it receives your appeal
Step 2

The Independent Review Organization gives you their answer.

If the review organization says yes to part or all of what you requested, we will do the following: For Medical Coverage: We must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we receive the decision from the review organization. For Drug Coverage: If the request is for prescription coverage, we must provide the drug coverage that was approved by the review organization within 24 hours after we receive the decision from the review organization. If the request is to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive the decision from the review organization. If this organization says no to part or all of your appeal, it means they agree with us that your request (or part of your request) for coverage for medical care should not be approved. (This is called “upholding the decision.” It is also called “turning down your appeal.”) There is a certain dollar value that must be in dispute to continue with the appeals process. For example, to continue and make another appeal at Level 3, the dollar value of the medical care coverage you are requesting must meet a certain minimum. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal, which means that the decision at Level 2 is final. The written notice you get from the Independent Review Organization will tell you how to find out the dollar amount to continue the appeals process.
Step 3

If your case meets the requirements, you choose whether you want to take your appeal further (Level 3, 4, and 5).

There are three additional levels in the appeals process after Level 2 (There are a total of five levels of appeal). If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. Level 3 Appeal: A judge who works for the Federal government will review your appeal and give you an answer. This judge is called an “Administrative Law Judge.” Level 4 Appeal: The Appeals Council will review your appeal and give you an answer. The Appeals Council works for the Federal government. Level 5 Appeal: A judge at the Federal District Court will review your appeal. For further information on appeals please refer to the Evidence of Coverage (EOC) Chapter 9. For appeals for Hospital discharge dates, covering other services like skilled nursing, outpatient services and home health care, please refer to Evidence of coverage Chapter 9 sections 7-10 or call Care1st Member Services.


You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions . Please contact Member Services at 1-800-544-0088 (TTY: 711)