2020/12/16 Council Agenda Packet

7.3.3 Appeals. a. An appeal is a request for review of a denial reduction, or termination of, or a failure to provide or make payment, in whole or in part for a Covered Service. An appeal must be submitted in writing to the Member Services Department no later than 180 days after the date of the denial, reduction, or termination of, or a failure to provide or make payment in whole or in part, for a Covered Service. The Enrollee should indicate the reason for the appeal and may include written comments, documents, records, or any relevant information. The Company will review the appeal and all information submitted. The Company will provide a written reply no later than 60 days after the receipt of a written request for an appeal. If the appeal involves: 1 A preauthorization, the Company will provide a written reply no later than 30 days after the receipt of a written request for an appeal. 2. Services deemed Experimental or Investigational, the Company will provide a written reply no later than 20 working days after the receipt of a written request for an appeal. 3. Services not yet provided for an alleged Dental Emergency, the Company will provide a reply no later than 72 hours of the receipt of a written request for an appeal. If the appeal is denied, the written reply will include the basis for the decision and other disclosures as required under state and federal laws. 7.3.4 Authorized Representative. Enrollees may authorize another person to represent the Enrollee and to whom the Company can communicate regarding a specific grievance or appeal The authorization must be in writing and signed by the Enrollee. The appeal process for an appeal submitted by a representative of the Enrollee will not commence until this authorization is received. If the written authorization is not received by the Company, the grievance or appeal will be closed. 7.4 Rights Not Transferable. The benefits of this Contract are not transferable. 7.5 Modification of Contract. Modification of this Contract becomes binding when it is in writing and signed by an officer of the Company 7.6 Force Majeure. If the provision of benefits available under this Contract is delayed or rendered impractical due to circumstances not within the Company's reasonable control including but not limited to, major disaster, labor dispute, complete or partial destruction of facilities, disability of a material number of the Participating Providers, or similar causes, the Company and its affiliates shall not have any liability or obligation on account of such delay or failure to provide benefits, except to refund the amount of the unearned advanced Premium held by the Company on the date such event occurs. The Company is required to make a good -faith effort to provide benefits, taking into account the impact of the event. 7.7 State Law and Forum. This Contract is entered into and delivered in the State of Washington. Washington law will govern the interpretation of provisions of this Contract unless federal law supersedes. 001 L-WA81 1 (5/20) 21